HIPAA Authorization For Use and Disclosure of Lab Test Results and Protected Health Information

Play Health Inc (“Play”) has contracted with Ash Wellness, Inc. (“Ash”) to facilitate laboratory testing through an independent clinical laboratory (“Laboratory”). Play has also contracted with SiPhox Inc. (“SiPhox”) to facilitate laboratory testing through their clinical laboratory. In order for SiPhox and Laboratory to share your laboratory test results with Play, you must complete this Authorization form.  

• By agreeing to this Authorization you authorize the Laboratory, Ash, and/or SiPhox to disclose the following information (“Information”) about you:  your laboratory test results along with demographic information about you that you supplied to Play  the assigned provider or your designated provider, to use and disclose your protected health information (PHI) for the purposes described in this Authorization. 

• You are authorizing the disclosure of the Information to: Play Heath, Inc., Ash Wellness, Inc., the third-party health care provider(s) engaged by Ash, SiPhox Inc., and/or the third-party health care provider(s) engaged by SiPhox to review your test results 

• This authorization is voluntary, and you may revoke it at any time by notifying Play as indicated below,  except to the extent that action has already been taken in reliance on your authorization.

• This authorization remains in effect until you terminate your relationship with Play (unless otherwise revoked by you).  

• You understand that to the extent Information disclosed pursuant to this Authorization such Information may no longer be protected by federal confidentiality law (the Health Insurance Portability and Accountability Act or “HIPAA”).

• Signing this Authorization is voluntary.  However, if you choose not to sign, you will not be able to access the laboratory testing services.

Contact Information and Process to Revoke Consent or HIPAA Authorization: If you have any questions about this Authorization or wish to revoke this Authorization, please contact Play at support@playhealth.com.