Legal name of person to be tested...

Authorization for Testing and Release of Protected Health Information:
I authorize Rotary Club of Martinsburg ("Rotary") via its contractor, City Hospital, Inc. dba Berkeley Medical Center ("BMC") to perform this laboratory testing, which may include venipuncture or capillary puncture to obtain a blood sample. • I understand that this testing is not a substitute for examination by a medical doctor and should not be used as the only means to diagnose a condition or lack of a condition. I understand that Rotary and BMC are not proposing a diagnosis, offering treatment, or offering medical advice by supplying these tests and their results to me. • I understand that I should contact my health care provider to discuss these results and their relation to my health and that it is my responsibility alone to do so. • I understand that in the event of a positive result for infectious disease testing, BMC is required by law to submit my test results to the West Virginia Health Department. • I understand that reportable conditions are denoted above with an asterisk (*). • I understand that payment for all tests must be made before or at the time of service. • I understand that the tests ordered will not be billed to my insurance, Medicare, Medicaid, or any other third party. • I understand that Rotary, BMC, and their affiliates disclaim liability for any costs, claims, injuries, actions, or damages suffered by an individual, no matter what their relationship, as a result of my participation in this Direct Access Testing program. My participation in this Direct Access Testing program is strictly voluntary. I agree to release Rotary, BMC, their affiliates, and other entities associated with the Direct Access Testing program from any liability whatsoever in connection with sample collection, testing, reporting, or any other aspect of this testing. • I understand that my test results are confidential and subject to the Health Insurance Portability and Accountability Act (HIPAA). • I understand that I have no obligation to authorize the release of my test results to any physician and choosing not to authorize the release of my results to a provider will not prevent my providers from obtaining a copy of these results in the future so long as there is a proper authorization. • I understand that my test results WILL be included in the WVU Medicine electronic health record and I can access the results through MyWVUChart. • I understand that my results will be provided to me by mail. • I understand that these results WILL NOT be forwarded by mail to my health provider. • I understand that my test results WILL be accessible through the West Virginia Health Information Network ("WVHIN"), unless I opt out by visiting www.connect.wvhin.org/optoutform or by calling WVHIN at 1.844.468.5755.

Signer's Relationship to Participant:    Date Signed:

You must electronically sign before submitting this registration - type your full name in the box below and then click the "Accept Signature" button to electronically sign this document:

Electronic Signature:  Accept Signature