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:
1784 Parrot Dr
San Mateo, CA 94402
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.