FOR BLOOD AND/OR BLOOD-DERIVED SAMPLES
I hereby authorize the provider performing the collection procedure for my blood and/or blood derived samples to disclose my protected health information to PKSD Holdings L.L.C, dba Drip IV Therapy (“Drip IV Therapy”). The only protected health information that my provider may disclose to Drip IV Therapy is that which is reasonably related to the receipt, testing, processing, cryopreservation, storage, and eventual release of my blood and/or blood-derived samples by Drip IV Therapy. The purpose of this disclosure is to allow Drip IV Therapy to have the information necessary to provide these services.
I hereby authorize Drip IV Therapy to disclose my protected health information to the provider performing my collection procedure and to other third party contractors. The only protected health information that Drip IV Therapy may disclose to my provider or to such contractors is that which is reasonably related to the collection and storage of my samples. The purpose of this disclosure is to allow my provider and the relevant contractors to have the information necessary to collect, process, and/or store my samples.
I understand that the information used or disclosed to Drip IV Therapy or my provider may be subject to re-disclosure and may then no longer be protected by federal privacy regulations.
I may revoke the authorization permitting my provider to disclose my information to Drip IV Therapy by notifying my provider in writing of my desire to revoke it. However, I understand that any action already taken by my provider or Drip IV Therapy reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization is in perpetuity after the date of signature below. I acknowledge and agree that Drip IV Therapy and its relevant contractors may retain my protected health information as long as they retain or store any of my samples.
I understand that my authorization is voluntary and I am not required to sign this form. My failure to sign this form will not otherwise affect my medical treatment. However, I further understand that my provider will not remove any blood, and Drip IV Therapy cannot process or store my samples, without this authorization.
I have read and understand the above information. I have received a copy of this form and I am either the patient or am authorized to act on behalf of the patient to sign this document, thus verifying authorization for the use or disclosure of the protected health information under the above stated terms.