Last Updated: August 1, 2021
This Privacy Authorization (the “Authorization”) authorizes Genebase Systems Inc.. and its testing laboratories and affiliates (collectively “Genebase”, “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 Genebase 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 Genebase 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 Genebase 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 Genebase 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.
Informed Consent for Telehealth Services
Last Updated: August 1, 2021
This Informed Consent for Telehealth Services (“Consent”) relates to telemedicine consultations, customer support, counseling or other related services including ordering, approving, processing, reviewing, evaluating, releasing, reporting, discussing and/or delivering results of laboratory tests (collectively, “Clinical Services”) arranged for by Genebase Systems Inc.. and its testing laboratories and affiliates (collectively “Genebase”, “us”, “we”, or “our”) provided by one or more of the following physician groups: 98point6 Physicians, PC, a Washington professional limited liability company, 98point6 New Jersey Physicians PC, a New Jersey company, 98point6 Michigan Physicians PC, a Michigan company, 98point6 Kansas Physicians, P.A., a Kansas company, 98point6 California Physicians PC, California company (collectively, “98point6”). This Consent includes:
- Your consent to receive Clinical Services from 98point6 and your associated rights and responsibilities; and
- Your agreement to receive services using telehealth technology.
- I am at least eighteen (18) years of age.
- I am the individual who will provide the sample for the Clinical Services I am seeking.
- I am voluntarily requesting or consenting to both the Services and Clinical Services without the influence of another person or party and understand 98point6 will determine whether or not the Services are medically appropriate for me.
- I agree to receive Clinical Services from 98point6. I understand that when seeking Clinical Services, I will not be in the same location or room as 98point6; however, when seeking Clinical Services, I agree to inform 98point6 of the state in which I am physically located and understand I will receive such services from a 98point6 Clinical Services provider licensed in that state.
- I understand that the Clinical Services are provided solely for informational purposes and do not constitute treatment of any condition, disease or illness. I understand that no treatment or prescription will be offered to me in connection with the Clinical Services. The Clinical Services do not replace visits with a healthcare professional of my choosing (hereinafter referred to as “healthcare professional”) and I agree to consult with a healthcare professional for medical advice, help, diagnosis and/or treatment.
- I understand any Clinical Services I receive, including any educational information, recommended next steps, and/or results, may be affected by incomplete or inaccurate data I provide or the Genebase product or services.
- I understand the level of care provided by 98point6 is to be the same level of care available to me through an in-person medical visit and that I have a right to withdraw this consent at any time and, if suggested by 98point6, pursue an in-person medical visit with a healthcare professional.
- I understand that my PHI and laboratory results may be shared with other healthcare professionals, including physicians, and counselors for purposes of providing the Clinical Services.
- I understand the potential risks of receiving Clinical Services via telehealth include but are not limited to: (i) limited or no availability of additional medical testing modalities to assist 98point6 in obtaining information beyond the laboratory test result; (ii) the inability of 98point6 to conduct a hands-on physical examination of me and my condition; (iii) the inability of 98point6 to review my complete medical record; and (iv) delays in reporting laboratory test results due to technical difficulties or interruptions, distortion of diagnostic images, or loss of specimens resulting from electronic transmission issues, unauthorized access to my PHI, or loss of my PHI due to technical failures. I will not hold Genebase or 98point6 responsible for any loss of or unauthorized access to my PHI.
- As a result of the Clinical Services I receive, I will not: (i) make medical decisions without consulting a healthcare professional or (ii) disregard or delay seeking medical advice from a healthcare professional.
- I authorize 98point6 to use the email address and/or phone number I provided in connection with my account to contact me in connection with the Clinical Services.
- In case of an emergency, I will dial 911 or directly access emergency services as are readily available for my use.
- If my laboratory results are critical, abnormal or inconclusive, I understand:
- 98point6 will attempt to contact me two (2) times to offer Clinical Services via telephone, text or video.
- The Clinical Services provided will include my laboratory results and may also include related educational information and potential next steps to be further discussed with a healthcare professional.
- If my results relate to a communicable disease or other reportable condition, Genebase and/or 98point6 may notify my local and/or state public health agency to the extent required under applicable law.
- If I am unable to be reached, 98point6 will inform Genebase and will instruct Genebase to populate your laboratory test results via the Genebase portal. 98point6 is not responsible for populating results via the Genebase portal. If I am unable to be reached or do not access my laboratory test results via the Genebase portal, I will not hold Genebase or 98point6 responsible for any harm associated with not receiving my laboratory test results.
- I am responsible for contacting and sharing the information provided by 98point6 or via the Genebase portal with a healthcare professional as soon as possible.
I consent to, understand and agree that:
- 98point6 will provide Clinical Services consistent with the prevailing standard(s) of care but makes no assurances or guarantees as to the Genebase laboratory test results.
- I have the right to review and receive copies of the Clinical Services received pursuant to the 98point6 policies and procedures, Notice of Privacy Practices, and applicable law. To submit my request, I will use the 98point6 Contact Us form or send an email to email@example.com.
- The laws of the state in which I am located will apply to my receipt of telehealth services.
- As an alternative to receiving telehealth services, I may elect to seek in-person medical services with a healthcare professional; however, I chose to proceed with the 98point6 Services at this time.
Informed Consent for Telehealth and HIV Testing
Last Updated: October 25, 2021
I understand that Human Immunodeficiency Virus (HIV) is an infection which weakens the human immune system. More details about HIV are available here.
The purpose of this HIV test is to determine whether HIV antigens and antibodies are present in my blood. Details about the types of testing that will be used on my blood, as well as the meaning of reactive (positive) and non-reactive (negative) test results are available here. The limitations of HIV testing include false positive test results, false negative test results, indeterminate results requiring re-test or additional testing, and the possibility that a recent infection may not be detected.
I understand that I have the opportunity to ask questions about HIV, this HIV test, and the possible results by calling 1-877-765-0027. Resources about HIV infection and interventions to reduce transmission are available here. I understand that there are treatment options and resources are available for HIV infection, and more information is available by contacting the phone number listed above or my local health department.
I understand that submitting to this test is my voluntary choice, and that free and anonymous testing may be available in the state where I am located, subject to applicable laws and regulations. I understand that my test results, if positive for HIV, may be reported to my state or local health department or similar epidemiological authorities, consistent with applicable state law, and that I may be asked to disclose a positive result to sexual partners or others who have had contact with my bodily fluids.
If I am located in Colorado or Hawaii I understand that I have the opportunity to engage in verbal counseling about sexually transmitted infections and about HIV specifically, and that by proceeding without counseling, I am voluntarily waiving my right to verbal counseling.