HIPAA PRIVACY AUTHORIZATION

Purpose: This authorization allows our partner healthcare providers and laboratories to share your protected health information, including results of test(s) you order, with us.

BY CLICKING ON THE “I HAVE READ AND ACCEPT THE HIPAA AUTHORIZATION” BUTTON DURING CHECKOUT, I REPRESENT THAT I HAVE READ THIS HIPAA PRIVACY AUTHORIZATION AND I HEREBY AUTHORIZE iNSIGHT LIFE SCIENCES, LLC (“COMPANY”) and ALL HEALTHCARE PROVIDERS, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“HEALTH CONSULTANTS”), AND THE TESTING LABORATORIES, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH COMPANY, TO USE, DISCLOSE, and receive disclosure of, PROTECTED 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 request(s) submitted by me or for me with my consent and the laboratory test values, results, reports, and information contained therein, which are the result of such request(s) (“Protected Healthcare Information”).

I specifically authorize the transfer and release of the Protected Healthcare Information to, between and among myself and the following individuals/organizations and their representatives, affiliates, employees, agents, and designees: (a) Company; (b) applicable Health Consultants and Labs; and (c) other Company partners for the purposes herein and as required or permitted by law.

The Protected Healthcare Information may be used or disclosed for the following purposes: (a) to perform the services requested by me or for me with my consent (including receiving, reviewing, and approving test requests and reviewing, processing, and delivering the test results); (b) to provide me with information and materials on treatment alternatives, health related offerings, and services and products which may assist me with health, wellness and overall care; (c) to conduct statistical research studies; and (d) as required or permitted under applicable state and federal laws.

I understand that I may opt to not have my personal information or Protected Healthcare Information used or disclosed for one or more of the purposes listed above. In order to opt-out, I must provide written notice to the Company as set forth below. I understand that such opt-out may affect the services I have voluntarily elected to receive.

This authorization is evidence of my informed decision to allow the release of my information to the parties referenced above. 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, as permitted by law.

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 and understand that my refusal may affect the services provided to me. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and would then no longer be protected by federal privacy regulations.

I may revoke this authorization in writing at any time. I understand that my revocation will not affect any use or disclosure already taken in reliance upon this authorization. My written revocation must be submitted to Company at: Insight Life Sciences, LLC, 4215 Beltwood Parkway, Suite 102, Dallas, Texas 75244; Email via Contact Form.

I understand that this authorization may be accepted by someone legally authorized to represent me.

Telehealth Consent & Acknowledgement Form

Purpose: This authorization form allows our healthcare providers to contact you in order to provide counseling over the phone if and when applicable.

BY CLICKING “I ACCEPT,” YOU ACKNOWLEDGE AND REPRESENT THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE SUBJECT TO THIS TELEHEALTH CONSENT & ACKNOWLEDGEMENT. IF YOU DO NOT CLICK “I ACCEPT,” YOU WILL NOT BE ABLE TO USE OR RECEIVE THE TELEHEALTH SERVICES MADE AVAILABLE BY COMPANY AND ITS CONTRACTED HEALTH CONSULTANTS. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I ACCEPT” BUTTON ON YOUR BEHALF.

I agree to receive this health care service provided by healthcare practitioner(s) affiliated with the company and its contracted health consultants (“Telehealth Consultant”). As a telehealth service, I understand that the healthcare practitioner(s) providing services to me may utilize certain telehealth platforms, such as interactive video and/or audio conferencing in real time, and may be located in a distant location.  The scope of services will be at the sole discretion of the healthcare practitioner(s) treating me, with no guarantee of diagnosis, treatment, or prescription.

I also understand that: (i) I have the right to withdraw my consent to the use of telehealth at any time; (ii) the telehealth services are subject to the same confidentiality and privacy protections that apply to other health care services offered through myapoe.com; (iii) I have access to all of my Protected Healthcare Information relating to the telehealth services in accordance with applicable laws and regulations; (iv) my Protected Healthcare Information may be shared with other individuals for further health care treatment and payment of healthcare services, and with those individuals/organizations set forth in the HIPAA Privacy Authorization above; (v) there are alternatives to a telehealth consultation, and I am choosing to participate in a telehealth consultation at this time; (vi) the Telehealth Consultant will not record or retain any video feed from the telehealth consultation; (vii) following the telehealth consultation, I may need to see an appropriately trained healthcare professional in-person for further treatment options.