Updated 12/1/2019

HIPAA Authorization to Use and Disclose Protected Health Information

 

1. I hereby authorize Mainstream Genomics to use and/or disclose the protected health information about me described below ("PHI") to my physician and other covered entities my physician deems appropriate.

2.  The PHI that may be used and/or disclosed is: my health history and family history.

3.  The PHI may be used and/or disclosed for the following purpose: risk assessment for genetic disease.

4.   This authorization shall remain in effect until: one year from my authorization.

5.   Mainstream Genomics may receive direct remuneration in exchange for disclosing the health information to my physician.

6.    I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this form.

7.    I understand that, as set forth in the notice of privacy practices, I have the right to revoke this authorization, in writing, at any time, except to the extent that Mainstream Genomics has acted in reliance upon it, by sending written notification to: 

Mainstream Genomics

1784 Parrot Dr

San Mateo, CA 94402

info@mainstreamgenomics.com

650-539-8842

8. I understand that I have the right to refuse to agree to this authorization.

9. I understand that PHI used or disclosed pursuant to this authorization may be redisclosed by the recipient and its confidentiality subject to the relevant federal or state law.