![]() ![]() I further understand that I have the right to revoke this authorization in writing at any time, which may affect my ability to use Lenco or particular functionality within the website/App. I understand that I have the right to inspect and copy the information that I have authorized to be disclosed. I understand that I may get a copy of this form after I sign it. I understand that I may refuse to authorize the release of any personal or health information as described herein and that my refusal to sign and thereby consent to this release will prevent the disclosure of such information for such purposes, but will not affect the health care services I presently receive, or will receive, from third parties, though it may affect my ability to register with Lenco and/or use Lenco for testing or particular functionality within the website/App. ![]() I am not required to use Lenco to schedule my testing. My healthcare treatment and benefits (including payment rights and eligibility, as applicable) will not be affected if I do not sign this form. I understand that signing this authorization is voluntary. I understand that the recipients of the information may benefit financially if I choose to utilize services through them. We may contract vendors to handle the foregoing tasks for us.We may share the Personal Information including Personal Health Information (PHI) with the insurance provider you identify to us, applicable plan administrator or their agent.We may use your Personal Information including Personal Health Information (PHI) for the purposes of insurance verification, determining eligibility, co-pay, deductible, co-insurance and/or cost-sharing obligations, and otherwise obtaining benefit plan information to use or share with your provider(s).We may share your Personal Information including Personal Health Information (PHI) with your physician or other clinician or provider to the extent either (1) you provide us with their contact information (using the name and contact information you provide or that they provide to us or update with us) and/or (2) they inform us of your patient status, to enable them to order and/or otherwise review testing and/or test results.We may store and transmit your appointment information and test results including to you and your ordering provider.I hereby authorize Lenco and its designees to access, disclose and release, as applicable, the following: This Authorization applies to all Dates of Service (DOS) scheduled through the Lenco website/App and testing otherwise conducted by Lenco and communicated using the website/App. You are referred to herein as “you”, “I” or the like. Any parent, guardian or other legal representative executing this Authorization represents and warrants he/she has the appropriate legal representative authority to do so on behalf of the patient or minor. Lenco may be referred to in this Authorization as "we," "us," "our" and the like. ("Lenco") includes its affiliates, parents, subsidiaries, successors and assigns. Any capitalized term used but not defined in this Authorization shall have the same meaning as in our underlying Terms and Conditions including the Privacy Policy. ![]()
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