Last Updated: August 1, 2021
This Privacy Authorization (the “Authorization”) authorizes Genovate Laboratories, Inc. and its testing laboratories and affiliates (collectively “Genovate”, “us”, “we”, or “our”) to collect, use and disclose my protected health information including (“PHI”) in connection with products and related services I request or to which I consent (collectively, the “Services”). By submitting my request to Genovate for the Services, I authorize my PHI to be collected, used and disclosed as provided by this Privacy Authorization or as disclosed to me when my PHI is collected. For purposes of this Authorization, I understand PHI includes the information I provide directly to Genovate as well as all information collected or obtained as a result of the Services (including, but not limited to, all values and information pertaining to such results). Additionally, to the extent necessary to receive the Services, I authorize the collection, use and disclosure of my PHI by and among the following persons, parties and/or entities including their staff, agents and designees (collectively, “Authorized Parties”):
- Healthcare providers, including accredited laboratories and those involved in ordering, approving, processing, reviewing, evaluating, releasing, reporting, discussing and/or delivering the Services;
- Other Genovate partners and affiliates as required or permitted by applicable law.
I understand Authorized Parties may collect, use or disclose my PHI to provide the Services to me and for related purposes including:
- For billing and payment services;
- For management and administrative purposes, such as conducting internal audits; and
- As required or permitted under applicable laws.
I understand that once my PHI has been received by an Authorized Party, such PHI may be disclosed to additional recipients and may no longer be protected by state and/or federal privacy regulations. I understand that, upon written request, I have the right to access (including to inspect and copy) my PHI that Authorized Parties have collected, used, or disclosed. This Authorization shall be effective immediately and will remain valid until I revoke it. I understand I may revoke my authorization at any time by providing written notice to Genovate at firstname.lastname@example.org. I understand that such revocation may affect the Services I receive and will not be effective to the extent Authorized Parties have taken action in reliance of this Authorization.
I understand that I have a right to receive a copy of this Privacy Authorization here: https://www.genovateconnect.com/download/privacy-authorization
By checking “I authorize the collection, use and disclosure of my PHI” and clicking the “Next” button below, I confirm I read, understand, accept, and authorize my PHI to be collected, used and disclosed pursuant to the terms of this Authorization.