Informed Consent

Health Tests


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

(Including Telehealth 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 a laboratory test (“Test”), including, without limitation, ordering of the Test, Test review services, receipt of Test results (“Results”), physician consultations via telemedicine (“Consults”), education sessions (“Education Sessions”), any customer support or counseling and any other related services provided by PWNHealth 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.

I acknowledge and agree to the following:

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 +1(805) 742-4254 or emailing help@mylabology.pwnhealth.com.

I authorize PWNHealth to use the email address and phone number I provided in connection with my Bio-Reference Laboratories 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 follow-up after receiving the Services. I am responsible for contacting PWNHealth's Care Coordination Team by calling +1(805) 742-4254 or emailing help@mylabology.pwnhealth.com 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 +1(805) 742-4254 or emailing help@mylabology.pwnhealth.com.

I have read this Informed Consent carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in the Services, including the performance of the Test(s) and the Consult, pursuant to the terms, conditions, standards, and requirements set forth herein, in the PWNHealth Terms of Use, PWNHealth Notice of Privacy Practices and PWNHealth Privacy Policy or as otherwise provided to me.

Data Authorization

I specifically authorize the transfer and release of my information as described herein and in the Privacy Policy and 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) Bio-Reference Laboratories and its affiliates, their staff and agents; and (b) PWNHealth and its affiliates, and their staff, agents, and health care providers, including physicians, 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

COVID-19


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.


PWNHEALTH WILL NOT PROVIDE ANY SERVICES FOR MEDICAL EMERGENCIES OR URGENT SITUATIONS. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL YOUR DOCTOR OR 911 IMMEDIATELY.

YOU SHOULD CONTACT YOUR HEALTHCARE PROVIDER IF YOUR SYMPTOMS GET WORSE OR YOU EXPERIENCE ANY NEW SYMPTOMS.

I agree to receive the services provided by PWNHealth, LLC (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 physician oversight of diagnostic testing for COVID-19 (“Tests”), including, without limitation, evaluation of the test request, ordering of Tests (if appropriate), receipt of Test results (“Results”), consultations via telemedicine with physicians or healthcare providers (“Consults”), customer support and any other related services provided by PWN or its service providers and partners (the “PWNHealth Services”). All clinical services, including services provided by physicians, will be provided through PWN Remote Care Services, PW Medical Professional or their contractually affiliated professional entities.

I acknowledge and agree to the following:

I understand that PWNHealth 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 email covid19@pwnhealth.comand I will be connected or directed to a member of the PWNHealth Care Coordination Team, including a physician, if requested or as otherwise applicable.

I authorize PWNHealth to use the email address and phone number I provided at the time I requested the Test (or that I updated by contacting PWN at the email below) to contact me in connection with the PWNHealth Services, including followup after a Consult. I am responsible for contacting PWN at the email address below to notify them of any changes to my mailing address, email address, phone number or other information that I provided in connection with the PWNHealth 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 emailing covid19@pwnhealth.com.

Data Authorization

I specifically authorize the transfer and release of my information as described herein and in the PWNHealth Notice of Privacy Practices, including my medical history that I provided, my Test Results and other identifiable health information, submitted by me or about me in connection with the PWNHealth Services, to, between and among myself and the following individuals, organizations and their representatives: (a) the company from whom I requested the 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 PWNHealth Services requested by me or performed with my consent 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 PWNHealth 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

I have read this Informed Consent carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in the PWNHealth Services, including the performance of the Test(s) that I have ordered and a Consult, pursuant to the terms, conditions, standards, and requirements set forth herein, in the PWNHealth Terms of Use and PWNHealth Notice of Privacy Practices or as otherwise provided to me.