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Consent and Data Authorization

BIOIQ, INC. AND ITS CONTRACTORS WILL NOT PROVIDE ANY SERVICES FOR MEDICAL EMERGENCIES OR URGENT SITUATIONS. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL YOUR DOCTOR OR 911 IMMEDIATELY.

YOU SHOULD CONTACT YOUR HEALTHCARE PROVIDER IF YOUR SYMPTOMS GET WORSE OR YOU EXPERIENCE ANY NEW SYMPTOMS.

BY SIGNING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS INFORMED CONSENT. IF YOU DO NOT SIGN THIS CONSENT, YOU WILL NOT BE ABLE TO USE OR RECEIVE THE SERVICES.

I consent to receive the services provided by BioIQ, Inc. and its contractors (collectively, "we" or "us") relating to diagnostic testing, including, without limitation, ordering of a Test (if appropriate), processing of specimens, and receipt of Test results (collectively, the “Testing Services”). All clinical services will be provided through BioIQ or its contractually affiliated professional entities. All laboratory testing services for the Test will be provided by qualified labs.

I acknowledge and agree to the following:

  • I am at least eighteen (18) years of age and I will provide the sample for the Test; or participant is a minor and I am the parent or legal guardian of the minor who will provide the sample for the test.
  • The information I have provided is correct to the best of my knowledge. I will not hold BioIQ or contractors responsible for any errors or omissions that I may have made in providing such information.
  • The Testing Services do not constitute treatment of any condition, disease or illness.
  • While the laboratories implement safeguards to avoid errors, as with all laboratory tests, there is a chance of a false positive or false negative result.
  • I am responsible for forwarding any results to my health care provider and for initiating follow up with such provider for care, diagnosis or medical treatment.
  • I acknowledge receipt of the Notice of Privacy Policies, which outlines various ways my health information may be used or disclosed, including for treatment, payment or healthcare operations in accordance with HIPAA or applicable international law.
  • By providing a cell phone number, I hereby consent to being contacted on my cell by BioIQ and any contractors providing Testing Services. I understand that such calls may be made by automatic telephone dialing systems or other computer assisted technology.  I will be given the opportunity to opt in or opt out of receiving text messages.  Cell phone company charges may apply to any calls or text I receive and shall be solely my responsibility.  If I do not want to be contacted on my cell phone, I will not provide my cell phone number.  If I later desire to have my cell phone number deleted as my contact number, I am responsible for changing the number in this application or informing BioIQ. 
  • By providing my email address, I hereby consent to being contacted on my email by BioIQ and any contractors providing Testing Services. Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. Any charges associated with the use of that email shall be solely my responsibility.  If I do not want to be contacted by email, I will not provide my email address.  If I later desire to have my email address deleted as my contact email, I am responsible for changing the email address in this application or informing BioIQ. 

I hereby release and hold harmless, on behalf of myself, my estate, my heirs and personal representative, BioIQ, and any Testing Services providers, and other partners including the ordering physician and other service providers and their affiliates, distributors, providers, employees, independent contractors, agents, directors, officers and shareholders and the successors and assigns of any of the preceding, from any and all claims and liability of any kind or nature whatsoever arising from or in connection with any services they provide, including Testing Services.

 

Data Authorization

We will collect and process your personal information, including name, date of birth, email address, mailing address, phone number, responses to COVID-19 screening questions (including symptoms), Test results, and other identifiable health information. I specifically authorize the transfer and release of my information as described herein and in the Privacy Policy, submitted by me or about me in connection with the Testing Services, to, between and among myself and the following individuals, organizations and their representatives: (a) BioIQ and its contractors; (b) BioIQ and its affiliates, and their staff, agents, and health care providers, including physicians; (c) the laboratory conducting the testing services; (d)program sponsor such as my employer; and (e) to public health authorities and/or any governmental entity that requires the reporting of certain test results, or as otherwise required by law, to facilitate and execute the Testing Services requested by me or performed with my consent and as required or permitted by law. You may revoke this consent at any time, in writing by email to privacyofficer@bioiq.com or by certified mail return receipt requested to BioIQ, Attn: Compliance Officer, 2300 Windy Ridge Pkwy SE, Suite 850S, Atlanta, GA 30339. I understand that revoking this authorization will not have any effect on actions already taken in reliance on this authorization.