HIPAA Consent Agreement
PURPOSE OF RELEASE
At the request of the patient/patient representative.
EXPIRATION OF AUTHORIZATION
(All tests ordered on this website will expire in 6 months after the date of order, unless otherwise indicated.)
U.S. BIO-CHEM and other health organizations are required to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
*I understand this authorization is voluntary. Treatment may not be conditioned on signing this authorization except if the authorization is for:
- Conducting research-related treatment
- Creating health information to provide to a 3rd party.*I may revoke this authorization at any time, provided I do so in writing and submit to: U.S. BIO-CHEM Medical Labs
4449 N Interstate 10 Service Rd W
Metairie, LA 70006
The revocation will take effect when U.S. BIO-CHEM receives it.
* I am entitled to receive a copy of this Authorization.”
We do not share your personal or financial information with any third party, nor do we authorize refunds on this website.