Authorization to Disclose Health Information
Color Genomics, Inc. (“Color”) is providing Covid-19 testing and related services (the “Covid-19 Services”) at the request of the institution that is paying for or otherwise making the Covid-19 Services available to you (e.g., the employer, school, or entity for which you perform or will perform services, or will enter their facilities) (the “C19 Program Sponsor”) to help guide the C19 Program Sponsor’s determination about the safety of admitting individuals to their facility/facilities during the Covid-19 pandemic (the “Authorized Use”). In connection with the Covid-19 Services, you will share certain personal and health information (“Protected Health Information” or “PHI”) with Color. For purposes of this authorization, your PHI also includes the information that Color generates about you in performing the Covid-19 Services, including your Covid-19 test results.
Purpose of this Authorization
To facilitate and execute the Covid-19 Services, and as required or permitted by applicable law, rule, or order, by signing this authorization form, you authorize Color to share your PHI with the C19 Program Sponsor in connection with the Authorized Use, each time the Covid-19 Services are performed.
Expiration of Authorization
This authorization will expire after five (5) years from the date of your authorization.
By signing this authorization form, you understand and acknowledge the following:
- I understand that I am not required to sign this authorization form, but that my refusal will make me ineligible to receive the Covid-19 Services through the C19 Program Sponsor’s program.
- I may revoke my authorization at any time, but to do so, I must request my revocation via electronic mail to email@example.com. My revocation will take effect upon Color’s receipt, except to the extent that Color has taken action in reliance upon this authorization prior to my revocation.
- I have received a copy, or have the right to receive a copy, of this authorization or to inspect the information contained therein by contacting firstname.lastname@example.org.
- I understand that Color is receiving payment from the C19 Program Sponsor or its affiliate in connection with the Covid-19 Services.
- I understand that this authorization shall apply for each instance that Color performs the Covid-19 Services for me, including, but not limited to, sharing my PHI with the C19 Program Sponsor each time I take a Covid-19 test if I repeat testing through the C19 Program Sponsor’s program.
- I understand that the information disclosed pursuant to this authorization may no longer be protected by federal or state medical confidentiality laws if the recipient of my PHI is not subject to such laws and may be re-disclosed by the recipient.
Last updated: August 20, 2020