Enprovider Network Informed Consent
PLEASE READ THIS INFORMED CONSENT CAREFULLY BEFORE USING OUR SERVICES. BY USING OUR SERVICES YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT.
ENPROVIDER NETWORK 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.
ENPROVIDER NETWORK SERVICES IS ONLY PROVIDING THE LIMITED SERVICES DESCRIBED BELOW. YOU SHOULD CONTACT YOUR HEALTHCARE PROVIDER IF YOUR SYMPTOMS GET WORSE OR YOU EXPERIENCE ANY NEW SYMPTOMS OR YOU ARE SEEKING MEDICAL CARE.General
1. Informed Consent.
I agree to receive the services (the “Enprovider Network Services”) provided by Enprovider Network, P.C. and certain affiliated professional entities including but not limited to Rudd, P.C. d/b/a Enprovider Network of Alaska, Enprovider Network of California, P.C., Enprovider Network of Kansas, P.A., Enprovider Network of Hawaii, Inc., Enprovider Network of New Jersey, P.C., and Enprovider Network of Texas, P.A. (collectively, the “Enprovider Network”, “we” or “us”) relating to physician authorizations for certain requested laboratory tests (“Test(s)”) and/or vaccination(s) (“Vaccination(s)”) provided by Laboratory Corporation of America Holdings and its affiliates and subsidiaries (collectively, “Labcorp”), and other services provided by the Enprovider Network, including, without limitation, evaluation of the Test or Vaccination request, ordering of Tests or Vaccinations (if appropriate and required), receipt of Test result(s) (“Result(s)”), educational consultations surrounding abnormal or critical Results if requested and provided via telemedicine with physicians or healthcare providers (“Consult(s)”) and any other related services provided by the Enprovider Network or its service providers (the “Enprovider Network Services”).
2. Acknowledgements.
I acknowledge, represent, warrant, authorize and agree to the following as a condition to receiving Enprovider Network Services:
(a) No physician or other healthcare provider in the Enprovider Network will be considered to be your physician or healthcare provider and no patient/physician relationship will be deemed to be created between you and any such physician or other healthcare provider. For the avoidance of doubt, no such physician or other healthcare provider shall be considered to be providing me with medical or professional care by reason of this Informed Consent. Enprovider Network Services do not constitute treatment of any condition, disease or illness.
(b) I am the individual who will provide the sample for the Test(s) that I am requesting.
(c) I am at least at the age of legal majority necessary to provide this Consent and the samples for the Test(s) in the state in which I am located (in most states that is eighteen (18) but you must confirm this for yourself).I am legally competent.
(d) I have read and understand the information provided about the Test(s) and/or Vaccination(s) on the Labcorp OnDemand website (https://www.ondemand.labcorp.com/), including without limitation, any risks associated with obtaining and providing the sample(s) for the Test(s) and relying on the Results therefrom. To the extent that I have any questions or concerns regarding the Test(s) and/or Vaccination(s), I have consulted with and obtained satisfactory answers from a physician or other qualified healthcare provider of my choice.
(e) All information I have provided in connection with the Enprovider Network Services is correct and complete. If there is additional information that is important to know before authorizing a Test and/or Vaccination or receiving other Enprovider Network Services, I have provided it. I will not hold Enprovider Network or its health care providers responsible for any errors or omissions that I may have made in providing such information. Without limiting the foregoing, at all times when I receive Enprovider Network Services, I will be physically located in the State identified as my place of residence in such information.
(f) Labcorp has arranged with Enprovider Network to provide the Enprovider Network Services in conjunction with the Test(s) and/or Vaccination(s) I have requested.
(g) In order to utilize certain Enprovider Network Services, I may be required to provide an appropriate sample for the Test(s), which may include a blood, urine, saliva or other type of sample. Depending on the Test requested, collection of such sample may take place at an employer sponsored event or a Labcorp collection center by appropriately qualified individuals or through the use of a patient collection kit provided to me. Enprovider Network Services is not responsible for the collection of any samples and is not liable for any injury that may occur in connection with obtaining any sample or if any sample is incorrectly labelled, stored or shipped.
(h) My health information and results may be shared with other Enprovider Network health care providers, including physicians, and counselors and Labcorp for purposes of providing treatment or in furtherance of healthcare operations. I may limit or revoke this authorization as further described in the Notice of Privacy Practices.
(i) While Enprovider Network and Labcorp implement safeguards to avoid errors, as with all laboratory tests, there is a chance of a false positive, a false negative result, or an inconclusive result. Among other things, samples provided to the Enprovider Network may not have been appropriately obtained, or may be damaged or corrupted in transit and as a result, Test results may be inaccurate or misleading. The Enprovider Network is not responsible for the lack of a viable sample, damage or corruption.
(j) I am responsible for checking for results notification and logging on to my Labcorp OnDemand account to view my results when available.
(k) If I receive an abnormal or critical result on a Test, I understand that Labcorp’s care coordination team may attempt to contact me to review the results, offer education and explain the next steps I should take. Labcorp’s care coordination team may leave me a voicemail but will not include my test results in any voicemail message. Such care coordination may include recommending that you contact an appropriate physician or other medical expert. For the avoidance of doubt the care coordination, itself, does not include medical advice. I also understand that if I am not able to be reached, Labcorp’s care coordination team may mail a follow-up letter to the residential address I provided when I purchased the Test (the letter will not include my Test results). If I receive an abnormal or critical result on a Test and have not connected with Labcorp’s care coordination team, I understand that I should not delay following up with my personal physician. In any event, if I have any questions regarding whether a result is abnormal or critical or as to the meaning of a result, it is my responsibility to follow up with my personal physician or other qualified healthcare provider. I understand that Labcorp’s care coordination team is not part of the Enprovider Network and the Enprovider Network is not responsible or liable for any acts or omissions of the Labcorp coordination team.
(l) I understand that upon receiving an abnormal or critical result on a Test, upon request, I will have the opportunity for one educational Consult with an appropriately licensed Enprovider Network physician or other qualified and appropriately licensed healthcare provider to respond to any questions I may have. All costs associated with such Consult are included in the professional component of the cost of the Test and I will not be charged any additional fees for such Consult.
(m) I certify that throughout the duration of the Enprovider Network Services I receive, including my Consult, I will be physically present in the state of residence I provided or other state of which I have notified Enprovider Network.
(n) I am responsible for forwarding any results of any Test(s) to my primary care or other personal physician and for initiating follow up with such physician for care, diagnosis or medical treatment.
(o) I will not make medical decisions without consulting a physician or other qualified and licensed healthcare provider or disregard medical advice from my physician or otherwise qualified and licensed healthcare provider or delay seeking such advice based on information as a result of the use of the Enprovider Network Services.
(p) If I receive an abnormal or critical result on certain Tests, my name, Test Result and other required information may be disclosed to federal or state health agencies to the extent required or permitted by applicable law.
(q) If I receive an abnormal or critical result on an STI 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 in certain circumstances these results may need to be reported to state public health authorities or similar governmental organizations as required by law.
(r) I understand that Enprovider Network and its service providers, and its successors and assigns, may use, copy, reproduce, modify, analyze, perform, display, distribute and otherwise disclose to third parties aggregate data that does not identify you for purposes of providing Enprovider Network Services to you; conducting research or analyses of such data; and designing, developing, implementing, modifying and/or improving new, current or future features, products and services of Enprovider Network using such data.
(s) I understand that Enprovider Network 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.
(t) An Enprovider Network physician will determine what criteria must be satisfied for me to be eligible to take or receive Test(s) or Vaccination(s).
(u) Any audio or video feed from the Consult will not be retained or recorded by Enprovider Network.
(v) My health and wellness information pertaining to telehealth services are governed by the Enprovider Network Terms of Use and Enprovider Network Notice of Privacy Practices.
(w) I may need to see a qualified and appropriately licensed physician or other health care provider in-person for diagnosis, treatment and care regardless of whether I have a Consult.
(x) There are potential risks associated with the use of technology, including disruptions, loss of data and technical difficulties.
(y) There are alternatives to the Enprovider Services, such as visiting a primary care provider, an emergency room, or an urgent care facility; however, I am choosing to proceed with the Enprovider Network Services at this time. In any event, use of the Enprovider Services will not preclude me from seeking further or additional medical or professional advice, care or services.
(z) I understand that if I have any questions before or after my Test and/or Vaccination(s), I can contact Enprovider Network at the email address or phone number below and I will be connected or directed to a member of the Labcorp care coordination team. The Enprovider Network does not guaranty any particular response time and in any event, if I have immediate need for medical or professional care, it is my responsibility to contact my primary care or another qualified and appropriately licensed physician or healthcare provider, contact 911, or visit an emergency room or urgent care center as appropriate.
(aa) THE ENPROVIDER NETWORK IS RELYING ON THE FOREGOING ACKNOWLEDGEMENTS, REPRESENTATIONS, WARRANTIES AND AGREEMENTS AND I WILL INDEMNIFY AND HOLD THE ENPROVIDER NETWORK HARMLESS FROM AND AGAINST ANY LOSS, LIABILITY, DAMAGE, CLAIM, JUDGMENT, COST AND EXPENSE, INCLUDING REASONABLE LEGAL FEES, COSTS AND EXPENSES, ARISING OUT OF ANY BREACH OF ANY OF THE FOREGOING.
3. Authorization
(a) I authorize Enprovider Network to use the email address and phone number I provided at the time I requested the Vaccination(s) or the Test on the Labcorp OnDemand website (or that I updated via the Labcorp OnDemand website) to contact me in connection with the Enprovider Network Services, including follow-up after a Consult. I am responsible for updating on the Labcorp OnDemand website any changes to my mailing address, email address, phone number or other information that I provided in connection with the Enprovider Network Services. '
(b) I understand that testing or vaccination is voluntary and that I may withdraw my consent to testing at any time prior to the completion of the Test(s) and/or Vaccination(s) by refusing to provide a sample or receive the Vaccination or in the case of a Test where a sample has already been obtained, by contacting Labcorp’s care coordination team at the email address below, in which case Labcorp will cease the testing as soon as commercially reasonable after receipt of such request. I understand, however, that the Enprovider Network will have no liability or responsibility for any acts or omissions occurring prior to the time that it receives actual notice of any such revocation.
4. Data Authorization.
(a) I specifically authorize the transfer and release of my information as described herein and in the Enprovider Network 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 Enprovider Network Services, to, between and among myself and the following individuals, organizations and their representatives: (1) Labcorp and its affiliates, their staff and agents; and (2) Enprovider Network and its affiliates, and their staff, agents, and health care providers, including physicians to facilitate and execute the Enprovider Network Services requested by me or performed with my consent and as required or permitted by law.
(b) 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 Enprovider Network Services available or provided to me. Once a Test and/or Vaccination(s) is in process there will be no refunds. 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; provided that no such revocation will have retroactive effect. This authorization will expire ten (10) years from the date of signature. The revocation or expiration of this authorization will not apply to any information already disclosed by the parties referenced in this authorization.
(c) My written revocation must be submitted to Enprovider Network at the contact information below.
I have read this Informed Consent carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in the Enprovider Network Services, including, without limitation, the performance of the Test(s) and/or Vaccination(s) that I have ordered and any Consult, pursuant to the terms, conditions, standards, and requirements set forth herein, in the Enprovider Network Terms of Use and Enprovider Network Notice of Privacy Practices and as otherwise provided to me.
Contact Information: support@labcorpemployerservices.com
844-251-6524
Enprovider Network
6992 Columbia Gateway Drive, Suite 100
Columbia, MD 21046
If I am providing this Consent on behalf of any other person, I represent, warrant, and agree that I am legally authorized under all applicable laws to do so and that I have full and complete knowledge of all matters covered by this Consent to make the representations, warranties and agreements on behalf of the person on whose behalf I am providing this Consent. I agree to indemnify and hold Enprovider Network harmless from and against any and all loss, liability, claim, damage, cause of action, cost and expense, including without limitation, reasonable legal fees and expenses, arising out of a breach by me of the foregoing representation, warranty or agreement.