If the Client chooses to cancel the services prior to collection, HealthBanks will issue a refund of the enrollment fee minus the credit card transaction fee charge, if; A) The unused collection kit is returned within 15 days of the expected due date, B)The collection kit seal is unopened, C) There is no damage to the collection kit.
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 HealthBanks Biotech Inc. The only protected health information that my provider may disclose to HealthBanks 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 HealthBanks. The purpose of this disclosure is to allow HealthBanks to have the information necessary to provide these services.
I hereby authorize HealthBanks 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 HealthBanks 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 HealthBanks 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 HealthBanks by notifying my provider in writing of my desire to revoke it. I may revoke the authorization permitting HealthBanks to disclose my information to my provider by notifying HealthBanks in writing of my desire to revoke it. However, I understand that any action already taken by my provider or HealthBanks in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
This authorization expires one year after the date of signature below. I acknowledge and agree that HealthBanks 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 HealthBanks 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.
©2021 All rights reserved
HealthBanks Biotech, Inc.