Example Consent

Effective as of August 4, 2014

Form of Provider Electronic Results Delivery Consent

By signing this consent, I authorize and certify to the following:

  1. I am at least 16 years of age.
  2. I consent to electronic results delivery and authorize my healthcare provider to deliver my medical records through Healthvana, Inc. (“Healthvana”), so that I may access my results from Healthvana’s website and mobile applications. I understand that only my STI Results for the screenings I receive from my provider will be delivered through Healthvana. These results include Chlamydia, Gonorrhea, Syphilis, HSV Typing and HIV.
  3. All personal information shared between my provider and Healthvana will be subject to all applicable Confidentiality and Privacy Laws.
  4. I acknowledge that receiving my STI Results electronically can never replace the consult of a Medical Provider. I understand that I may return to my provider for a consultation with a Medical Professional regarding my STI Results. I understand that it is up to me and my provider to decide upon treatment if necessary.
  5. I understand that this authorization and release expires 3 years from the date hereof, and that I may revoke it, in writing, effective upon receipt by my provider. I further understand that no party shall have any liability for disclosing information in accordance with this release and authorization prior to receipt of any such written revocation.
  6. I understand that if I disclose the STI Results to a third party once they are disclosed to me then they may be subject to redisclosure by the recipient and not protected by Confidentiality and Privacy Laws.
  7. I understand that my provider may not condition testing or treatment on my signing this form.
  8. I understand that a photocopy or fax of this form is as valid as the original.

I have read the foregoing and consent to receive my health records electronically.