I hereby authorize (i) Nutritional Biochemistry, Inc. (with its affiliates and staff, “NBI”), (ii) Lab Testing API, LTD (with its affiliates and staff, “Lab Testing API”) and (iii) PWN Remote Care Services, (with its affiliates and administrative services provider, “PWN”), including its physicians, their staff, agents and designees, including PWNHealth, LLC, as agent and administrative services provider and the laboratories that perform services requested by or consented by me (“PWN Parties”) to use and disclose health information about me in the manner and for the purposes stated below.
This authorization applies to the use and disclosure of the following information about me: all information in requests(s) submitted by me or about me with my consent and the laboratory test values/results/information which are the result of the request(s) so submitted.
For avoidance of doubt, I specifically authorize the transfer and release of this information to, between and among myself and the following individuals, organizations and their representatives:
- NBI
- Lab Testing API and its affiliates, their staff and agents;
- PWN and its affiliates, physicians and their staff and agents (including PWNHealth, LLC);
- The designated PWN physician of record and its staff, agents and designees;
- The applicable laboratory of record and its staff and agents; and
- Certain providers for the purposes herein, and as required or permitted by law.
The information which is the subject of this authorization will be used or disclosed for the following purposes:
- to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing and approving a laboratory request; reviewing, processing and delivering the laboratory test value(s)/result(s));
- to provide me with information and materials on health-related offerings and services and products which may assist me with health and wellness or be of interest to me; and
- to conduct statistical research studies, and as required or permitted under state and federal laws. Remuneration may be received in exchange therefor. I may opt to not have my personal information disclosed for some purposes above with prior written notice to NBI, PWN or Lab Testing API, as applicable, as set forth below. I understand that such opt-out may affect the services I have voluntarily elected.
This authorization evidences my informed decision to allow release of the information to the parties referenced in this authorization. This authorization is effective immediately and will expire ten years after the date of this authorization.
Upon my written request, I may inspect or copy the information that I have permitted to be used or disclosed, if permitted by law. NBI, PWN Parties or Lab Testing API may receive payment or other remuneration related to the use and disclosures herein.
I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization in which case my refusal may affect the services provided to me. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by certain privacy laws. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization have acted in reliance upon this authorization. My written revocation must be submitted to, as applicable, NBI at:
c/o NBI
3525 Del Mar Heights Rd #350
San Diego, CA 92130
Signature:
Acknowledged electronically on: