BY CLICKING ON THE “I AGREE TO TERMS & CONDITIONS” BUTTON ON THE EPI+GEN CHDTM QUESTIONNAIRE PAGE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS PAGE AND I HEREBY AUTHORIZE CARDIO DIAGNOSTICS, INC., INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES, TO COLLECT, STORE, USE AND DISCLOSE 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/information which are the result of such request(s).
For avoidance of doubt, I specifically authorize the transfer and release of this information to, between and among myself and the following individuals/organizations and their representatives, affiliates, staff, agents, and designees: (a) Company; (b) your insurance company; (c) any physician that you designate; (d) applicable Health Consultants and Labs; and (e) other Company partners for the purposes herein and as required or permitted by law.
The information subject to this authorization may be used or disclosed for the following purposes: (a) to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing, and approving test requests and reviewing, processing, and delivering the test values/results); (b) for treatment, health care operations, and payment services; (c) to conduct statistical research studies using de-identified test results; and (d) as required or permitted under applicable state and federal laws. I may opt to not have my personal information used or disclosed for some of the purposes 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 upon clicking the ‘submit’ button on the questionnaire page. 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 terms & conditions. I have the right to refuse to agree to terms & conditions 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 using the contact information below.
To opt not to have your personal information used or disclosed for some of the purposes above, to request written inspection of the information you have permitted to be used or disclosed, or to submit a written revocation of this authorization, contact the Company at: Cardio Diagnostics, Inc., 2500 Crosspark Road, Suite W245, Coralville, IA 52241; Email: firstname.lastname@example.org.
I understand that no information obtained in the course of completing this questionnaire, which identifies me will be disclosed to non-covered entities, as defined in HIPAA, without my written consent.
I acknowledge and understand that by completing this questionnaire
I have read this document carefully, and all my questions were answered to my satisfaction. I acknowledge and understand that the Company may update their Terms & Conditions, and I am able to receive a copy of the latest Terms & Conditions by contacting the Company at: Cardio Diagnostics, Inc., 2500 Crosspark Road, Suite W245, Coralville, IA 52241; Email: email@example.com. I hereby consent to participate in this program pursuant to the terms, conditions, standards, and requirements set forth herein or as otherwise provided to me.