Terms of Service
HIPAA AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION
My Safe PassTM Olfactory test application information used for Test completion.
The site (http://www.mysafepass.us) is operated by MSP. Throughout the Site, the terms"we", "us" and "our" refer to MSP. MSP offers this Site, including all information, tools, and services available from this Site to you, the user, conditioned upon your acceptance of all terms, conditions, policies, and notices stated here.
By visiting our Site and/or purchasing something from us, you engage in our "Service" and agree to be bound by the following terms and conditions, including those additional terms and conditions and policies referenced herein and/or available by hyperlink. These Terms apply to all users of the Site, including without limitation users who are browsers, vendors, customers, merchants, and/or contributors of content. In the event of an inconsistency between this agreement and any additional terms or policies referenced herein, the provisions of the additional terms or policies shall control.
Please read these Terms carefully before accessing or using our Site. By accessing or using any part of the Site, you agree to be bound by these Terms. If you do not agree to all the Terms of this Agreement, then you may not access the Site or use any Service. If these Terms are considered an offer, acceptance is expressly limited to these Terms.
Any new features or tools which are added to the current store shall also be subject to the Terms. You can review the most current version of the Terms at any time on this page. We reserve the right to update, change or replace any part of these Terms by posting updates and/or changes to our Site. It is your responsibility to check this page periodically for changes. Your continued use of or access to the Site following the posting of any changes constitutes acceptance of those changes.
I. THE PATIENT/USER
This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
I authorize My Safe Pass tm and its associated owners, (“Authorized Party”) to use or disclose all information gathered, Hereinafter known as the “Medical Records.”
The Authorized Party has my authorization to disclose Medical Records to the provider which was selected by the user in the drop-down menu.
The reason for this authorization is to provide gathered data to the Patient/User selected provider.
This authorization will terminate upon provider's request.
VI. ACKNOWLEDGMENT OF RIGHTS.
I understand that I have the right to revoke this authorization, in writing and at any time, except where uses or disclosures have already been made based upon my original permission. I might not be able to revoke this authorization if its purpose was to obtain insurance.
I understand that uses and disclosures already made based upon my original permission cannot be taken back.
I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy Standards.