Authorization for Disclosure of Protected Health Information


By agreeing to these terms, I authorize US BioTek Laboratories ("USBTL"), COVID Response Partners, PLLC (“CRP”), and their employees, affiliates, and contractors to disclose my demographic information that I provide to them and the results of my SARS-CoV-2 PCR polymerase chain reaction (“PCR”) tests to governmental authorities such as one or more local public health jurisdictions, state department(s) of health, the Center for Disease Control and Prevention (“CDC”), and other governmental health agencies, as required by law. In addition, I authorize USBTL and CRP to use and disclose my health information in anonymized form for internal research programs, with research institutions, and with local, federal, and state agencies as part of USBTL and CRP’s efforts to better understand SARS-CoV-2 and develop effective measures against it.

I understand that the purposes for these uses and disclosures of my demographic information and PCR test results (collectively, my “Health Information”) may include the provision of the PCR testing services to me, coordinating my need for self-isolation, medical care, or treatment, and/or tracking the spread of SARS-CoV-2.

I understand that my Health Information is subject to federal and state privacy laws, including the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. Section 1320d) (“HIPAA”), and cannot be disclosed without my written authorization unless otherwise provided for under those laws. I understand that disclosure of Health Information under this Authorization may be subject to re-disclosure by any person or entity receiving my Health Information and may no longer be protected by HIPAA.

I understand that I may revoke this Authorization by notifying CRP in writing at of my desire to revoke it. However, I understand that any action already taken in reliance on this Authorization cannot be reversed, and my revocation will not affect those actions. This Authorization expires after one year from my signature date. I understand that I have the right to request and obtain a paper version of this Authorization.