12/17/2023 0 Comments Bigben travelBy accepting these terms and conditions and using this site and the services within it, you agree to be bound and abide by the terms and conditions for use as set forth here and in rules and regulations as amended by Company from time to time. ![]() This service is intended to provide a platform for convenience for services that are not intended to be reimbursable by any third party payer or program and that are requested directly by the patient knowingly and voluntarily, in view of the foregoing. Company hereby grants you the non-exclusive, non-transferrable right and license to use this site and service. (the “Company”) on a self-pay basis without a physician’s order or the requirement to establish medical necessity. This portal (the “Application”) permits you to order and request the performance of certain diagnostic laboratory testing performed by Great Lakes Medical Laboratory, Inc. This authorization expires one (1) year for the date of execution and a photocopy of this authorization shall be valid as the original.ġ. However, I understand that any action already taken in reliance of this authorization cannot be reversed and my revocation will not affect those actions.ģ. I may revoke this authorization by notifying the above-named recipient in writing of my desire to revoke it. I understand that the information used or disclosed may be subject to re-disclosure by the person or class persons or facility receiving it and would then no longer be protected by federal privacy regulations.Ģ. This authorization includes but is not limited to laboratory results, verbal communication of test results.ġ. Results from Covid-19 PCR Nasal swab screening outlining undersigned’s medical and/or physical condition. The specific information to be disclosed is: ![]() _ Consulate General of The People's Republic of China in Chicago_ Please release information to one (1) or more of the following location: The following specific person, class of persons or facility is authorized to make the requested disclosure: ![]() I hereby authorize use or disclosure of protected health information about me as described below.
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