I hereby authorize: to release my lab request/order form to Lab @ Home US for the purposes of booking an at home test and having it delivered to the laboratory selected by my healthcare practitioner.

ACKNOWLEDGEMENT OF UNDERSTANDING:

• I understand that this authorization is for a one time use only.


• I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance on it.


• I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations.


• that the program or person, which is to make the disclosure, has already acted in reliance on it.


• I understand that an email, photocopy or fax of this form is the same as the original.