NOTE: PWNHealth provides physician oversight in order for us to order the labs for our patients and customers. This informed consent describes your rights and options as it relates to working with PWNHealth.
BY CLICKING “I ACCEPT,” YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DO NOT CLICK “I ACCEPT”, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.
General Informed Consent
I agree to receive the services provided by PWNHealth (the administrative services provider of the professional entities), PWN Remote Care Services, PW Medical Professional and certain other affiliated professional entities (collectively, “PWNHealth”, “we” or “us”) relating to ordering laboratory tests (“Tests”), including, without limitation, ordering of Tests, test review services, testing, receipt of Test results (“Results”), physician consultations via telemedicine (“Consults”), any customer support or counseling and any other related services provided by PWN or its service providers and partners (the “Services”). All clinical Services, including Services provided by physicians, will be provided through PWN Remote Care Services, PW Medical Professional or their affiliated professional entities.
If you have ordered an HIV Test (including as part of a panel), please also review the Informed Consent to Perform HIV Testing immediately following this General Informed Consent.
I acknowledge and agree to the following:
● The Services do not constitute treatment or diagnosis of any condition, disease or illness, except for Consults for Treatment Conditions as described below.
● I am responsible for checking my email for results notification and logging on to my account to view my results when available.
● If I receive an abnormal result on a Test, I understand that PWNHealth's Care Coordination Team will attempt to call me to review the results, offer education and explain the next steps I should take. PWNHealth’s Care Coordination Team may leave me a voicemail but will not include my test results in any voicemail message. I also understand that if I am not able to be reached, PWNHealth's Care Coordination Team will mail a follow-up letter to the residential address I provided when I purchased my test (the letter will not include my test results). If I receive an abnormal result and have not connected with PWNHealth’s Care Coordination Team, I understand that I should not delay following up with my personal physician.
● If I receive an abnormal result on certain STD Tests, my name and result will be disclosed to my state health agency in accordance with applicable law.
● If I receive an abnormal result on an STD Test, it is important that I notify my sexual and needle sharing partners and follow up with my personal physician to receive treatment.
I understand that Services, including Consults, are delivered by health care providers who are not in the same physical location as I am using electronic communications, information technology or other means, including the electronic transmission of personal health information. I also understand that:
I understand that if I have any questions before or after my Test, I can contact PWNHealth's Care Coordination Team by calling by calling 888-362-4321 or emailing [email protected].
I authorize PWN to use the email address and phone number I provided in connection with my account at the time I purchased my Test(s) (or that I updated by contacting PWNHealth's Care Coordination Team as described below) to contact me in connection with the Services, including followup after a Consult. I am responsible for contacting PWNHealth's Care Coordination Team by calling by calling 888-362-4321 or emailing [email protected] to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the Services.
I understand that testing is voluntary and that I may withdraw my consent to testing at any time prior to the completion of the Test(s) by contacting PWNHealth's Care Coordination Team by calling 888-362-4321 or emailing [email protected].
I hereby authorize PWN Remote Care Services (with its affiliates and administrative services providers, “Company”), including its physicians, their staff, agents and designees, PWNHealth, LLC, as agent and administrative services provider, and the laboratories that perform services requested by or consented to be me (“Company Parties”) to 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 the request(s) submitted by me or about me with my consent and the laboratory test values/results/information which are the result of the request(s) so submitted.
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: (a) Health Testing Centers, LLC and its affiliates, their staff and agents; (b) Company and its affiliates, and their staff and agents (including PWNHealth, LLC); (c) the designated Company physician of record and its staff, agents and designees; (d) the applicable laboratory of record and its staff and agents; and (e) certain providers for the purposes herein, and as required or permitted by law.
The information which is the subject of this authorization will be used or disclosed for the following purposes: (a) to facilitate and execute the services requested me or performed with my consent (including receiving, reviewing and approving a laboratory request; reviewing, processing and delivering the laboratory test value(s)/result(s)); (b) for treatment, health care operations and payment services; (c) to provide me with information and materials on treatment alternatives, health related offerings and services and products which may assist me with health, wellness and overall care or be of interest to me; and (d) to conduct statistical research studies, and as required or permitted under state and federal laws. Remuneration may be received in exchange therefore. I may opt to not have my personal information disclosed for some purposes above with prior written notice to the Company as set forth below. I understand that such opt-out may affect the services I have voluntarily elected.
This authorization evidences my informed decision to allow release of the information to the parties referenced in this authorization. This authorization is effective immediately and will expire ten years after the date of this authorization.
I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization in which case my refusal may affect the services provided to me. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization have acted in reliance upon this authorization. My written revocation must be submitted to PWN’s General Counsel at:
AttN: General Counsel
123 West 18th Street, 8th Floor
New York, NY 10011
If signed by someone legally authorized to represent the individual, please describe that authority and attach document(s) evidencing that authority.
By signing or acknowledging this authorization electronically, I agree to its terms and representations.
Signature: acknowledged electronically or in writing
Date: [INSET DATE OR DATE STAMP]
Informed Consent to Perform HIV Testing
(This Consent Applies Only If You Purchase An HIV Test)
I have been provided with and I understand the following information regarding HIV testing:
I understand that the law prohibits discrimination based on an individual’s HIV status. Services are available if I believe I have experienced discrimination based on my HIV status.
I understand that the law protects the confidentiality of test results. As required by state law, if I am positive for HIV, my name and results will be reported to my state’s health department. I also understand that my health information and results may be shared with other PWN health care providers, including physicians, and counselors for purposes of providing care to me.
I understand that testing is voluntary and that I may withdraw my consent to testing at any time prior to the completion of the laboratory test by contacting PWNHealth's Care Coordination Team by calling 888-362-4321 or emailing [email protected].
I have read and understand the information that has been provided to me. I have been given the opportunity to ask questions about HIV testing and all of my questions have been answered to my satisfaction.