Choose Healthy Life HIPAA Authorization

Quest Diagnostics is the laboratory that will conduct the testing that is part of the Choose Healthy Life Wellness Program. Quest Diagnostics and Choose Health Life are committed to gaining and maintaining your trust, especially concerning the privacy of your information. Quest Diagnostics complies with a federal law called HIPAA, which stands for the Health Insurance Portability and Accountability Act of 1996. HIPAA gives patients certain protections about the use of their health information. Quest Diagnostics is required to get your permission when sharing your health information with other people and organizations in certain situations, like for the Choose Healthy Life Wellness Program.

In order to fully participate in the Choose Healthy Life Wellness Program, Quest Diagnostics needs to share some of your personal health information (also known as your protected health information) with people that are not Quest Diagnostics employees. Sharing your protected health information will help Choose Healthy Life perform follow-up activities and provide you with additional information for the Program. More details about the information that is shared and who will receive it is listed below.

Quest Diagnostics and Choose Healthy Life take your privacy very seriously and want to be sure that you are fully informed about how your data will be shared. Once you read through this Authorization, Quest Diagnostics is asking you for permission to share your protected health information in connection with your participation in the Choose Healthy Life Wellness Program. When you sign this form that is called a HIPAA Authorization, you give Quest Diagnostics permission to share your protected health information as part of this Program.

Authorization to Share PHI
I give my permission and authorize Quest Diagnostics Incorporated and its subsidiaries and affiliates (“Quest”) to collect, use and disclose my protected health information (also called PHI) as described in this Authorization to the groups and individuals that are named as Recipients listed below and that are arranging for Quest testing as part of the Choose Healthy Life Wellness Program, which we will call the Program in this Authorization. This Program is paid for by someone other than me and there is no charge to me for the Program.

The Purpose of this authorization is for Quest to share my PHI with the Recipients so they can arrange for my testing, help deliver test results to me, help me understand my test results, and help me connect with healthcare professionals and health related programs.

“PHI” means protected health information and includes my personal information (e.g., name, address, age, gender, and other personal information) and any and all information related the testing performed/to be performed by Quest as part of the Program, including but not limited to, information to book appointment(s), my test results, and my laboratory report(s).

Recipients means the following groups and individuals may receive my PHI : United Way of New York City, Detroit Association of Black Organizations (DABO), Leadership Council for Healthy Communities (LCHC), MLK Community Resources Collaborative the church contracted by the above mentioned recipients to facilitate the Program (“Church”); the Church’s on-site health navigator that may be in direct contact with me to help with the program; and the following individuals that I identify (please insert the name of any other individuals you authorize as a recipient of your PHI).

Once the Recipients have my PHI, it may no longer be protected under federal privacy law called HIPAA and it could be re-disclosed or re-shared to others.

This Authorization takes effect when I sign it; my authorization will expire on December 31, 2024. Notice to Patient:
• This authorization is voluntary and you may refuse to sign it.
• Quest cannot require you to sign this Authorization as a condition to providing its regular testing services, but because the Recipients identified above are arranging for testing as part of the Program according to their eligibility requirements, including use of a health navigator, if you do not sign this Authorization you cannot participate in the Program or receive testing as part of the Program.
• You may ask for a copy of your PHI that will be used by or disclosed or shared to the Recipients;
• Quest must give you a copy of this signed authorization, upon request;
• This Authorization only covers your PHI that is collected, used or disclosed by Quest.
• You have the right to revoke or take back this authorization at any time, by sending a written notice of revocation to CHLRevokeHIPAA@questdiagnostics.com. Your revocation only applies to uses and disclosures of your information after we receive it, and does not affect any prior use or disclosure Quest made in reliance upon this authorization.