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@example.com.
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 firstname.lastname@example.org 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@example.com.
I specifically authorize the transfer and release of my information as described herein and in the Notice of Privacy Practices available to me when seeking and purchasing the Services, including my lab test Results and other identifiable health information, submitted by me or about me in connection with the Services, to, between and among myself and the following individuals, organizations and their representatives: (a) the company through which I purchased the applicable laboratory test and its affiliates, their staff and agents; (b) PWNHealth and its affiliates, and their staff, agents, and health care providers, including physicians, and (c) the laboratory conducting the laboratory testing services to facilitate and execute the Services requested by 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)), and as required or permitted by law.
I understand that I have a right to receive a copy of the above data disclosure 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 privacy laws. 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. This authorization will expire ten (10) years from the date of signature. My written revocation must be submitted to PWNHealth’s General Counsel at:
PWN Remote Care Services
c/o PWNHealth, LLC
Attn: General Counsel
123 West 18th Street, 8th Floor
New York, NY 10011
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 by calling 888-362-4321 or emailing firstname.lastname@example.org.
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.