AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) VIA E-MAIL

  • PHI is "Protected Health Information" as defined by HIPAA. Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email. When we send you an email, or you send us an email, the information that is sent is not encrypted. This 
means a third party may be able to access the information and read it since it is transmitted over the Internet. 
In addition, once you receive the email, someone may be able to access your email account and read it.

    I authorize InOut Labs to disclose or provide protected health information (lab orders and lab results only) directly to me or to those I designate at the e-mail address(es) I have provided on this form. I also understand that it is my responsibility to notify InOut Labs of any change in this information. Any disclosure via e-mail is subject to the re-disclosure statement within this authorization.

    As stated in InOut Labs’ Notice of Privacy Practice, I have the right to revoke or terminate this authorization by submitting a written request to InOut Labs. This can be done in person or by mailing a request to the testing InOut Labs.

    RE-DISCLOSURE I understand that InOut Labs has no control over who may have access to the e-mail address I have listed to receive my protected health information. The information disclosed will no longer be protected by the requirements of the Privacy Rule and future disclosure is not the responsibility of InOut Labs.
  • e.g. Your health care provider.
  • Date Format: MM slash DD slash YYYY