genetworx.com
Open in
urlscan Pro
34.75.179.1
Public Scan
Submitted URL: https://e.genetworxlaboratory.com/MzEwLVlVTy0xNzYAAAGFB3pwmAVGMpm0TLHfKFKi4HMYxcsh87OtFI7trFV4c5XX_tPUpiaRLRufooE6I0Eqo3z96AI=
Effective URL: https://genetworx.com/?mkt_tok=MzEwLVlVTy0xNzYAAAGFB3pwmFmyqBxvHJpfGIiS3xOOzxqXSNtRaxSA_fGsJyyObyiLwOFcm7yd_SwjQxmbBJQ...
Submission: On June 16 via api from US — Scanned from DE
Effective URL: https://genetworx.com/?mkt_tok=MzEwLVlVTy0xNzYAAAGFB3pwmFmyqBxvHJpfGIiS3xOOzxqXSNtRaxSA_fGsJyyObyiLwOFcm7yd_SwjQxmbBJQ...
Submission: On June 16 via api from US — Scanned from DE
Form analysis 6 forms found in the DOM
GET https://genetworx.com
<form class="elementor-search-form" role="search" action="https://genetworx.com" method="get">
<div class="elementor-search-form__container">
<input placeholder="Search GENETWORx" class="elementor-search-form__input" type="search" name="s" title="Search" value="">
<button class="elementor-search-form__submit" type="submit" title="Search" aria-label="Search">
<i aria-hidden="true" class="fas fa-search"></i> <span class="elementor-screen-only">Search</span>
</button>
</div>
</form>GET https://genetworx.com
<form class="elementor-search-form" role="search" action="https://genetworx.com" method="get">
<div class="elementor-search-form__container">
<input placeholder="Search GENETWORx" class="elementor-search-form__input" type="search" name="s" title="Search" value="">
<button class="elementor-search-form__submit" type="submit" title="Search" aria-label="Search">
<i aria-hidden="true" class="fas fa-search"></i> <span class="elementor-screen-only">Search</span>
</button>
</div>
</form><form id="mktoForm_1073" novalidate="novalidate" class="mktoForm mktoHasWidth mktoLayoutLeft" style="font-family: Helvetica, Arial, sans-serif; font-size: 13px; color: rgb(51, 51, 51); width: 1601px;">
<style type="text/css">
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<div class="mktoOffset mktoHasWidth" style="width: 10px;"></div>
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<div class="mktoHtmlText mktoHasWidth" style="width: 260px;">Fields marked with * are required.</div>
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<div class="mktoClear"></div>
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<div class="mktoGutter mktoHasWidth" style="width: 10px;"></div><select id="MKT_Group__c" name="MKT_Group__c" aria-labelledby="LblMKT_Group__c InstructMKT_Group__c" class="mktoField mktoHasWidth mktoRequired" aria-required="true"
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<option value="">I am a(n)...</option>
<option value="GXC">Individual</option>
<option value="GX">Business</option>
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<div class="mktoFieldDescriptor mktoFormCol" style="margin-bottom: 10px;">
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<div class="mktoFieldWrap mktoRequiredField"><label for="FirstName" id="LblFirstName" class="mktoLabel mktoHasWidth" style="width: 100px;">
<div class="mktoAsterix">*</div>
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<div class="mktoGutter mktoHasWidth" style="width: 10px;"></div><input id="FirstName" name="FirstName" placeholder="First Name*" maxlength="255" aria-labelledby="LblFirstName InstructFirstName" type="text"
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<div class="mktoFieldWrap mktoRequiredField"><label for="Email" id="LblEmail" class="mktoLabel mktoHasWidth" style="width: 100px;">
<div class="mktoAsterix">*</div>
</label>
<div class="mktoGutter mktoHasWidth" style="width: 10px;"></div><input id="Email" name="Email" placeholder="Email Address*" maxlength="255" aria-labelledby="LblEmail InstructEmail" type="email"
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<div class="mktoFieldDescriptor mktoFormCol" style="margin-bottom: 10px;">
<div class="mktoOffset" style="width: 10px;"></div>
<div class="mktoFieldWrap"><label for="State" id="LblState" class="mktoLabel mktoHasWidth" style="width: 100px;">
<div class="mktoAsterix">*</div>
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<div class="mktoGutter mktoHasWidth" style="width: 10px;"></div><select id="State" name="State" aria-labelledby="LblState InstructState" class="mktoField mktoHasWidth" style="width: 150px;">
<option value="">Select State</option>
<option value="Alaska">AK</option>
<option value="Alabama">AL</option>
<option value="Arkansas">AR</option>
<option value="Arizona">AZ</option>
<option value="California">CA</option>
<option value="Colorado">CO</option>
<option value="Connecticut">CT</option>
<option value="Delaware">DE</option>
<option value="Florida">FL</option>
<option value="Georgia">GA</option>
<option value="Hawaii">HI</option>
<option value="Iowa">IA</option>
<option value="Idaho">ID</option>
<option value="Illinois">IL</option>
<option value="Indiana">IN</option>
<option value="Kansas">KS</option>
<option value="Kentucky">KY</option>
<option value="Louisiana">LA</option>
<option value="Massachusetts">MA</option>
<option value="Maryland">MD</option>
<option value="Maine">ME</option>
<option value="Michigan">MI</option>
<option value="Minnesota">MN</option>
<option value="Missouri">MO</option>
<option value="Mississippi">MS</option>
<option value="Montana">MT</option>
<option value="North Carolina">NC</option>
<option value="North Dakota">ND</option>
<option value="Nebraska">NE</option>
<option value="New Hampshire">NH</option>
<option value="New Jersey">NJ</option>
<option value="New Mexico">NM</option>
<option value="Nevada">NV</option>
<option value="New York">NY</option>
<option value="Ohio">OH</option>
<option value="Oklahoma">OK</option>
<option value="Oregon">OR</option>
<option value="Pennsylvania">PA</option>
<option value="Rhode Island">RI</option>
<option value="South Carolina">SC</option>
<option value="South Dakota">SD</option>
<option value="Tennessee">TN</option>
<option value="Texas">TX</option>
<option value="Utah">UT</option>
<option value="Virginia">VA</option>
<option value="Vermont">VT</option>
<option value="Washington">WA</option>
<option value="Wisconsin">WI</option>
<option value="West Virginia">WV</option>
<option value="Wyoming">WY</option>
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<div class="mktoClear"></div>
</div>
<div class="mktoClear"></div>
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<div class="mktoFieldDescriptor mktoFormCol" style="margin-bottom: 10px;">
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<div class="mktoFieldWrap mktoRequiredField"><label for="PostalCode" id="LblPostalCode" class="mktoLabel mktoHasWidth" style="width: 100px;">
<div class="mktoAsterix">*</div>
</label>
<div class="mktoGutter mktoHasWidth" style="width: 10px;"></div><input id="PostalCode" name="PostalCode" placeholder="Zip*" maxlength="255" aria-labelledby="LblPostalCode InstructPostalCode" type="text"
class="mktoField mktoTextField mktoHasWidth mktoRequired" aria-required="true" style="width: 150px;"><span id="InstructPostalCode" tabindex="-1" class="mktoInstruction"></span>
<div class="mktoClear"></div>
</div>
<div class="mktoClear"></div>
</div>
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow"><input type="hidden" name="Webform_Submitted__c" class="mktoField mktoFieldDescriptor mktoFormCol" value="GX COVID-19 Test Inquiry" style="margin-bottom: 10px;">
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow"><input type="hidden" name="GCLID__c" class="mktoField mktoFieldDescriptor mktoFormCol" value="" style="margin-bottom: 10px;">
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow"><input type="hidden" name="Last_Web_Medium__c" class="mktoField mktoFieldDescriptor mktoFormCol" value="" style="margin-bottom: 10px;">
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow"><input type="hidden" name="Last_Web_Source__c" class="mktoField mktoFieldDescriptor mktoFormCol" value="" style="margin-bottom: 10px;">
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow"><input type="hidden" name="Last_Web_Campaign__c" class="mktoField mktoFieldDescriptor mktoFormCol" value="" style="margin-bottom: 10px;">
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow"><input type="hidden" name="Last_Web_Content__c" class="mktoField mktoFieldDescriptor mktoFormCol" value="" style="margin-bottom: 10px;">
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow"><input type="hidden" name="Last_Web_Term__c" class="mktoField mktoFieldDescriptor mktoFormCol" value="" style="margin-bottom: 10px;">
<div class="mktoClear"></div>
</div>
<div class="mktoFormRow">
<div class="mktoFormCol" style="margin-bottom: 10px;">
<div class="mktoOffset mktoHasWidth" style="width: 10px;"></div>
<div class="mktoFieldWrap">
<div class="mktoHtmlText mktoHasWidth" style="width: 320px;">
<div class="_updated_consent">
<p>Your privacy is important to us. By clicking Submit, you confirm that you have reviewed our privacy policy and agree to our terms of use and that your information may be shared with RCA and affiliated companies, who may contact you to
keep you updated with important health-related information.</p>
<p>By entering your mobile number and clicking Submit, you also consent that RCA and affiliated companies may send you SMS messages using autodialing technology from our primary messaging code 73529 for health-related information and as
described in our terms of use in our privacy policy. Std. msg & data rates apply. Reply HELP or help, STOP to cancel. Msg freq may vary. Your consent is not required as a condition of purchasing any product, good, or service.</p>
<h5>Informed Consent to Participate in Medical Record Registry</h5>
<p>GENETWORx and its affiliates (“We, Us, Our”) are creating a medical record registry to help Us predict, prevent, and treat disease (the “Registry”). The Registry matches patients’ laboratory test information with medical history
information obtained from health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will use data analytics, artificial intelligence
and other automated tools to analyze the data in the Registry for various purposes including improving Our patient care and outcomes, lowering costs, recommending products and services to support your health and wellbeing, or sharing
data with other healthcare providers, medical researchers, drug developers, and clinical trial teams to advance medical science.</p>
<h6>SUMMARY OF INFORMATION</h6>
<ul>
<li>This Informed Consent and Authorization asks for your permission to participate in the Registry by allowing Us to obtain, store, use and share your information.</li>
<li>Participation is voluntary and will not affect your care in any way.</li>
<li>We may share your de-identified information with third parties without any further consent or authorization.</li>
<li>Once collected by Us, your information will be stored with industry standard security safeguards.</li>
</ul>
<h6>WHAT IS A REGISTRY?</h6>
<p>A Registry is a collection of information about people who have various diseases or conditions, or who receive various tests or treatments. The Registry holds patient information according to the data security standards of federal and
state law.</p>
<p>This Informed Consent provides you with information that you should know and understand before agreeing to add your information to the Registry. Please read this Informed Consent carefully.</p>
<h6>WHAT INFORMATION IS BEING COLLECTED FOR THE REGISTRY?</h6>
<p>Information (data) will be collected from your health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will collect health,
demographic, claims, billing, pharmacy and medical records. All information will be collected from your records of the care you have received in the past ten years, are receiving or will be receiving in the future for so long as you
continue to participate in the Registry.</p>
<h6>HOW WILL INFORMATION IN THE REGISTRY BE USED?</h6>
<p>The purpose of this Registry is to help Us predict, prevent, and treat disease. Information in the Registry may be used for medical, research, commercial, marketing or other business purposes including, but not limited to providing
healthcare or care coordination services, communicating with you about diagnostic tests, clinical trials or other healthcare related services that may be of interest based upon your medical history including marketing and promoting our
services and the services of third parties, aggregating and analyzing data to understand or improve Our testing, treatment services, and operations, research to predict, prevent and treat disease(s), de-identifying data to create data
sets that will be shared with third parties such as medical researchers and drug developers to advance medical treatment, for administrative purposes, and for other legally permissible purposes.</p>
<h6>HOW WILL MY HEALTH INFORMATION BE SHARED?</h6>
<p>We may share your identifiable information with Our affiliates under common ownership to use for the same purposes for which We may use your information. We may also share your information with third party service providers performing
services on our behalf. We may share your information for legal purposes including as we deem necessary to respond to a subpoena, regulation, binding order of a data protection agency, legal process, governmental request or other legal
or regulatory process. We may also share your information in business transfers including in connection with a merger, acquisition, the sale of company assets, or in any similar transaction, or to the extent as may be required in the
unlikely event of insolvency bankruptcy, or a receivership. Once your information is de-identified is no longer personal information and can be used by Us and shared with third parties for any purposes, including sale to third parties.
</p>
<h6>HOW LONG IS YOUR PARTICIPATION IN THE REGISTRY?</h6>
<p>With your authorization, we will collect your historic and future health information when you enroll in the Registry. You may stop participating in the Registry at any time.</p>
<h6>WHAT RISKS ARE KNOWN ABOUT BEING IN THE REGISTRY?</h6>
<p>We will comply with the applicable HIPAA standards that protect your health and personal information. However, there is the potential risk your participation in this Registry may expose your information (including health information)
stored in the Registry. <br> There may be other risks that are not known at this time.</p>
<h6>WHAT BENEFIT CAN YOU EXPECT?</h6>
<p>You may receive a benefit from participation in the Registry if We are able to provide you information about diagnostic tests or clinical studies for which you may be eligible. For research related purposes, you will not receive any
direct benefit.</p>
<h6>WHAT ARE THE FINANCIAL CONSIDERATIONS?</h6>
<p><strong>Cost</strong> <br> There will be no cost to you for your participation in this Registry. <br> <strong>Payment for Participation</strong><br> You will not be paid for your participation in this Registry or for any future use of
the information in the Registry.</p>
<h6>VOLUNTARY PARTICIPATION/WITHDRAWAL</h6>
<p>Your decision to take part in this Registry is completely voluntary. You are free to choose not to take part in the Registry and may change your mind and withdraw at any time. Your relationship with Us and your care through Us (now or
in the future) will not be affected in any way if you withdraw or refuse to participate. You will not lose any benefits to which you are otherwise entitled.</p>
<h6>WHAT IF YOU DECIDE NOT TO GIVE PERMISSION TO USE AND GIVE OUT YOUR INFORMATION?</h6>
<p>By clicking Submit on this informed consent form and authorization, you are giving permission for Us to obtain, use and share your information as described above. If you refuse to give permission, you are declining to be in this
Registry. <br> Information that is already in the Registry cannot be removed, deleted or withdrawn.</p>
<h6>QUESTIONS</h6>
<p>If you have any additional questions, or if you wish to report a problem that may be related to this Registry, Our Privacy Officer can be reached by email at <a href="mailto:privacy@recoverycoa.com">privacy@recoverycoa.com</a> or at
484-803-9655 during business hours. <br> Do not click Submit on this informed consent form unless you have had a chance to ask questions and have received satisfactory answers to all your questions.</p>
<h5>AGREEMENT TO PARTICIPATE IN REGISTRY AND AUTHORIZATION</h5>
<p>To enroll in the GENETWORx Registry, you or your legal representative must click Submit on this Authorization. By clicking Submit on this page, you are confirming that you have read the information in the “Informed Consent to
Participate in the Medical Record Registry” document and you are voluntarily agreeing to be in the Registry.</p>
<p><strong>By clicking Submit on this Authorization, you authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefits manager, medical facility, health information exchange,
health information aggregator or other health care provider that has provided payment, treatment or services to you to release and disclose the following records to GENETWORx to be incorporated into the Registry:</strong></p>
<p>Any and all information (including personal, health, demographic, claims, billing, pharmacy and medical records) created in the ten years prior to the date of this Authorization or at any time after the date of this Authorization for
as long as this Authorization remains in effect.</p>
<p>The records provided to the Registry will include the following highly protected information (known as Sensitive PHI)</p>
<ul>
<li>Substance abuse records (including alcoholism)</li>
<li>AIDS or HIV treatment records</li>
<li>Mental health services (does not include psychotherapy notes)</li>
<li>Genetic information</li>
</ul>
<p><strong>By clicking Submit on this Authorization, you authorize GENETWORx to use and share your information in the Registry for medical, research, commercial, marketing or other business purposes including, but not limited to, those
described in the Informed Consent.</strong></p>
<p>This Authorization involves the use of a Registry and will remain in effect until you revoke it.<br> You may change your mind and revoke (take back) the right to use your protected health information at any time. However, even if you
revoke this Authorization, the Registry may still maintain, use or disclose information it has already collected about you. If you revoke this Authorization, GENETWORx will no longer collect new information about you for the Registry.
To revoke this Authorization, you must email <a href="mailto:privacy@recoverycoa.com">privacy@recoverycoa.com</a>.</p>
<p>I understand that information disclosed to the Registry pursuant to this Authorization may be subject to re-disclosure and may no longer be protected by federal and state law.</p>
<p>By clicking Submit, you are voluntarily agreeing to be in this Registry and to the use and disclosure of your protected health information as described above. Your health information is being released to GENETWORx at your request. You
understand that your treatment, payment, enrollment or eligibility for benefits does not depend on whether you click Submit on this Authorization and participate in the Registry.</p>
<p>To manage or change opt in preferences or revoke this Authorization, you must call 844-335-2482.</p>
<p>Upon request, you will be given a signed copy of this Authorization form to keep for your personal records.</p>
</div>
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<option value="AE">ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST</option>
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<p>Your privacy is important to us. By clicking Submit, you confirm that you have reviewed our privacy policy and agree to our terms of use and that your information may be shared with RCA and affiliated companies, who may
contact you to keep you updated with important health-related information.</p>
<p>By entering your mobile number and clicking Submit, you also consent that RCA and affiliated companies may send you SMS messages using autodialing technology from our primary messaging code 73529 for health-related
information and as described in our terms of use in our privacy policy. Std. msg & data rates apply. Reply HELP or help, STOP to cancel. Msg freq may vary.Your consent is not required as a condition of purchasing any
product, good, or service.</p>
<h5>Informed Consent to Participate in Medical Record Registry</h5>
<p>GENETWORx and its affiliates (“We, Us, Our”) are creating a medical record registry to help Us predict, prevent, and treat disease (the “Registry”). The Registry matches patients’ laboratory test information with medical
history information obtained from health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will use data analytics,
artificial intelligence and other automated tools to analyze the data in the Registry for various purposes including improving Our patient care and outcomes, lowering costs, recommending products and services to support
your health and wellbeing, or sharing data with other healthcare providers, medical researchers, drug developers, and clinical trial teams to advance medical science.</p>
<h6>SUMMARY OF INFORMATION</h6>
<ul>
<li>This Informed Consent and Authorization asks for your permission to participate in the Registry by allowing Us to obtain, store, use and share your information.</li>
<li>Participation is voluntary and will not affect your care in any way. </li>
<li>We may share your de-identified information with third parties without any further consent or authorization. </li>
<li>Once collected by Us, your information will be stored with industry standard security safeguards.</li>
</ul>
<h6>WHAT IS A REGISTRY?</h6>
<p>A Registry is a collection of information about people who have various diseases or conditions, or who receive various tests or treatments. The Registry holds patient information according to the data security standards
of federal and state law. </p>
<p>This Informed Consent provides you with information that you should know and understand before agreeing to add your information to the Registry. Please read this Informed Consent carefully.</p>
<h6>WHAT INFORMATION IS BEING COLLECTED FOR THE REGISTRY?</h6>
<p>Information (data) will be collected from your health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will collect
health, demographic, claims, billing, pharmacy and medical records. All information will be collected from your records of the care you have received in the past ten years, are receiving or will be receiving in the future
for so long as you continue to participate in the Registry.</p>
<h6>HOW WILL INFORMATION IN THE REGISTRY BE USED?</h6>
<p>The purpose of this Registry is to help Us predict, prevent, and treat disease. Information in the Registry may be used for medical, research, commercial, marketing or other business purposes including, but not limited to
providing healthcare or care coordination services, communicating with you about diagnostic tests, clinical trials or other healthcare related services that may be of interest based upon your medical history including
marketing and promoting our services and the services of third parties, aggregating and analyzing data to understand or improve Our testing, treatment services, and operations, research to predict, prevent and treat
disease(s), de-identifying data to create data sets that will be shared with third parties such as medical researchers and drug developers to advance medical treatment, for administrative purposes, and for other legally
permissible purposes.</p>
<h6>HOW WILL MY HEALTH INFORMATION BE SHARED?</h6>
<p>We may share your identifiable information with Our affiliates under common ownership to use for the same purposes for which We may use your information. We may also share your information with third party service
providers performing services on our behalf. We may share your information for legal purposes including as we deem necessary to respond to a subpoena, regulation, binding order of a data protection agency, legal process,
governmental request or other legal or regulatory process. We may also share your information in business transfers including in connection with a merger, acquisition, the sale of company assets, or in any similar
transaction, or to the extent as may be required in the unlikely event of insolvency bankruptcy, or a receivership. Once your information is de-identified is no longer personal information and can be used by Us and shared
with third parties for any purposes, including sale to third parties.</p>
<h6>HOW LONG IS YOUR PARTICIPATION IN THE REGISTRY?</h6>
<p>With your authorization, we will collect your historic and future health information when you enroll in the Registry. You may stop participating in the Registry at any time.</p>
<h6>WHAT RISKS ARE KNOWN ABOUT BEING IN THE REGISTRY?</h6>
<p>We will comply with the applicable HIPAA standards that protect your health and personal information. However, there is the potential risk your participation in this Registry may expose your information (including health
information) stored in the Registry. <br>There may be other risks that are not known at this time. </p>
<h6>WHAT BENEFIT CAN YOU EXPECT?</h6>
<p>You may receive a benefit from participation in the Registry if We are able to provide you information about diagnostic tests or clinical studies for which you may be eligible. For research related purposes, you will not
receive any direct benefit. </p>
<h6>WHAT ARE THE FINANCIAL CONSIDERATIONS?</h6>
<p><strong>Cost</strong> <br>There will be no cost to you for your participation in this Registry. <br><strong>Payment for Participation</strong><br>You will not be paid for your participation in this Registry or for any
future use of the information in the Registry.</p>
<h6>VOLUNTARY PARTICIPATION/WITHDRAWAL</h6>
<p>Your decision to take part in this Registry is completely voluntary. You are free to choose not to take part in the Registry and may change your mind and withdraw at any time. Your relationship with Us and your care
through Us (now or in the future) will not be affected in any way if you withdraw or refuse to participate. You will not lose any benefits to which you are otherwise entitled.</p>
<h6>WHAT IF YOU DECIDE NOT TO GIVE PERMISSION TO USE AND GIVE OUT YOUR INFORMATION?</h6>
<p>By clicking Submit on this informed consent form and authorization, you are giving permission for Us to obtain, use and share your information as described above. If you refuse to give permission, you are declining to be
in this Registry. <br>Information that is already in the Registry cannot be removed, deleted or withdrawn. </p>
<h6>QUESTIONS</h6>
<p>If you have any additional questions, or if you wish to report a problem that may be related to this Registry, Our Privacy Officer can be reached by email at
<a href="mailto:privacy@recoverycoa.com">privacy@recoverycoa.com</a> or at 484-803-9655 during business hours. <br> Do not click Submit on this informed consent form unless you have had a chance to ask questions and have
received satisfactory answers to all your questions. </p>
<h5>AGREEMENT TO PARTICIPATE IN REGISTRY AND AUTHORIZATION</h5>
<p>To enroll in the GENETWORx Registry, you or your legal representative must click Submit on this Authorization. By clicking Submit on this page, you are confirming that you have read the information in the “Informed
Consent to Participate in the Medical Record Registry” document and you are voluntarily agreeing to be in the Registry.</p>
<p><strong>By clicking Submit on this Authorization, you authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefits manager, medical facility, health information
exchange, health information aggregator or other health care provider that has provided payment, treatment or services to you to release and disclose the following records to GENETWORx to be incorporated into the
Registry:</strong></p>
<p>Any and all information (including personal, health, demographic, claims, billing, pharmacy and medical records) created in the ten years prior to the date of this Authorization or at any time after the date of this
Authorization for as long as this Authorization remains in effect. </p>
<p>The records provided to the Registry will include the following highly protected information (known as Sensitive PHI)</p>
<ul>
<li>Substance abuse records (including alcoholism)</li>
<li>AIDS or HIV treatment records</li>
<li>Mental health services (does not include psychotherapy notes)</li>
<li>Genetic information</li>
</ul>
<p><strong>By clicking Submit on this Authorization, you authorize GENETWORx to use and share your information in the Registry for medical, research, commercial, marketing or other business purposes including, but not
limited to, those described in the Informed Consent.</strong></p>
<p>This Authorization involves the use of a Registry and will remain in effect until you revoke it.<br>You may change your mind and revoke (take back) the right to use your protected health information at any time. However,
even if you revoke this Authorization, the Registry may still maintain, use or disclose information it has already collected about you. If you revoke this Authorization, GENETWORx will no longer collect new information
about you for the Registry. To revoke this Authorization, you must email <a href="mailto:privacy@recoverycoa.com">privacy@recoverycoa.com</a>.</p>
<p>I understand that information disclosed to the Registry pursuant to this Authorization may be subject to re-disclosure and may no longer be protected by federal and state law.</p>
<p>By clicking Submit, you are voluntarily agreeing to be in this Registry and to the use and disclosure of your protected health information as described above. Your health information is being released to GENETWORx at your
request. You understand that your treatment, payment, enrollment or eligibility for benefits does not depend on whether you click Submit on this Authorization and participate in the Registry.</p>
<p>To manage or change opt in preferences or revoke this Authorization, you must call 844-335-2482.</p>
<p>Upon request, you will be given a signed copy of this Authorization form to keep for your personal records.</p>
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<p>Your privacy is important to us. By clicking Submit, you confirm that you have reviewed our privacy policy and agree to our terms of use and that your information may be shared with RCA and affiliated companies, who may
contact you to keep you updated with important health-related information.</p>
<p>By entering your mobile number and clicking Submit, you also consent that RCA and affiliated companies may send you SMS messages using autodialing technology from our primary messaging code 73529 for health-related
information and as described in our terms of use in our privacy policy. Std. msg & data rates apply. Reply HELP or help, STOP to cancel. Msg freq may vary.Your consent is not required as a condition of purchasing any
product, good, or service.</p>
<h5>Informed Consent to Participate in Medical Record Registry</h5>
<p>GENETWORx and its affiliates (“We, Us, Our”) are creating a medical record registry to help Us predict, prevent, and treat disease (the “Registry”). The Registry matches patients’ laboratory test information with medical
history information obtained from health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will use data analytics,
artificial intelligence and other automated tools to analyze the data in the Registry for various purposes including improving Our patient care and outcomes, lowering costs, recommending products and services to support
your health and wellbeing, or sharing data with other healthcare providers, medical researchers, drug developers, and clinical trial teams to advance medical science.</p>
<h6>SUMMARY OF INFORMATION</h6>
<ul>
<li>This Informed Consent and Authorization asks for your permission to participate in the Registry by allowing Us to obtain, store, use and share your information.</li>
<li>Participation is voluntary and will not affect your care in any way. </li>
<li>We may share your de-identified information with third parties without any further consent or authorization. </li>
<li>Once collected by Us, your information will be stored with industry standard security safeguards.</li>
</ul>
<h6>WHAT IS A REGISTRY?</h6>
<p>A Registry is a collection of information about people who have various diseases or conditions, or who receive various tests or treatments. The Registry holds patient information according to the data security standards
of federal and state law. </p>
<p>This Informed Consent provides you with information that you should know and understand before agreeing to add your information to the Registry. Please read this Informed Consent carefully.</p>
<h6>WHAT INFORMATION IS BEING COLLECTED FOR THE REGISTRY?</h6>
<p>Information (data) will be collected from your health plans, physicians, health care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and other medical facilities. We will collect
health, demographic, claims, billing, pharmacy and medical records. All information will be collected from your records of the care you have received in the past ten years, are receiving or will be receiving in the future
for so long as you continue to participate in the Registry.</p>
<h6>HOW WILL INFORMATION IN THE REGISTRY BE USED?</h6>
<p>The purpose of this Registry is to help Us predict, prevent, and treat disease. Information in the Registry may be used for medical, research, commercial, marketing or other business purposes including, but not limited to
providing healthcare or care coordination services, communicating with you about diagnostic tests, clinical trials or other healthcare related services that may be of interest based upon your medical history including
marketing and promoting our services and the services of third parties, aggregating and analyzing data to understand or improve Our testing, treatment services, and operations, research to predict, prevent and treat
disease(s), de-identifying data to create data sets that will be shared with third parties such as medical researchers and drug developers to advance medical treatment, for administrative purposes, and for other legally
permissible purposes.</p>
<h6>HOW WILL MY HEALTH INFORMATION BE SHARED?</h6>
<p>We may share your identifiable information with Our affiliates under common ownership to use for the same purposes for which We may use your information. We may also share your information with third party service
providers performing services on our behalf. We may share your information for legal purposes including as we deem necessary to respond to a subpoena, regulation, binding order of a data protection agency, legal process,
governmental request or other legal or regulatory process. We may also share your information in business transfers including in connection with a merger, acquisition, the sale of company assets, or in any similar
transaction, or to the extent as may be required in the unlikely event of insolvency bankruptcy, or a receivership. Once your information is de-identified is no longer personal information and can be used by Us and shared
with third parties for any purposes, including sale to third parties.</p>
<h6>HOW LONG IS YOUR PARTICIPATION IN THE REGISTRY?</h6>
<p>With your authorization, we will collect your historic and future health information when you enroll in the Registry. You may stop participating in the Registry at any time.</p>
<h6>WHAT RISKS ARE KNOWN ABOUT BEING IN THE REGISTRY?</h6>
<p>We will comply with the applicable HIPAA standards that protect your health and personal information. However, there is the potential risk your participation in this Registry may expose your information (including health
information) stored in the Registry. <br>There may be other risks that are not known at this time. </p>
<h6>WHAT BENEFIT CAN YOU EXPECT?</h6>
<p>You may receive a benefit from participation in the Registry if We are able to provide you information about diagnostic tests or clinical studies for which you may be eligible. For research related purposes, you will not
receive any direct benefit. </p>
<h6>WHAT ARE THE FINANCIAL CONSIDERATIONS?</h6>
<p><strong>Cost</strong> <br>There will be no cost to you for your participation in this Registry. <br><strong>Payment for Participation</strong><br>You will not be paid for your participation in this Registry or for any
future use of the information in the Registry.</p>
<h6>VOLUNTARY PARTICIPATION/WITHDRAWAL</h6>
<p>Your decision to take part in this Registry is completely voluntary. You are free to choose not to take part in the Registry and may change your mind and withdraw at any time. Your relationship with Us and your care
through Us (now or in the future) will not be affected in any way if you withdraw or refuse to participate. You will not lose any benefits to which you are otherwise entitled.</p>
<h6>WHAT IF YOU DECIDE NOT TO GIVE PERMISSION TO USE AND GIVE OUT YOUR INFORMATION?</h6>
<p>By clicking Submit on this informed consent form and authorization, you are giving permission for Us to obtain, use and share your information as described above. If you refuse to give permission, you are declining to be
in this Registry. <br>Information that is already in the Registry cannot be removed, deleted or withdrawn. </p>
<h6>QUESTIONS</h6>
<p>If you have any additional questions, or if you wish to report a problem that may be related to this Registry, Our Privacy Officer can be reached by email at
<a href="mailto:privacy@recoverycoa.com">privacy@recoverycoa.com</a> or at 484-803-9655 during business hours. <br> Do not click Submit on this informed consent form unless you have had a chance to ask questions and have
received satisfactory answers to all your questions. </p>
<h5>AGREEMENT TO PARTICIPATE IN REGISTRY AND AUTHORIZATION</h5>
<p>To enroll in the GENETWORx Registry, you or your legal representative must click Submit on this Authorization. By clicking Submit on this page, you are confirming that you have read the information in the “Informed
Consent to Participate in the Medical Record Registry” document and you are voluntarily agreeing to be in the Registry.</p>
<p><strong>By clicking Submit on this Authorization, you authorize any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefits manager, medical facility, health information
exchange, health information aggregator or other health care provider that has provided payment, treatment or services to you to release and disclose the following records to GENETWORx to be incorporated into the
Registry:</strong></p>
<p>Any and all information (including personal, health, demographic, claims, billing, pharmacy and medical records) created in the ten years prior to the date of this Authorization or at any time after the date of this
Authorization for as long as this Authorization remains in effect. </p>
<p>The records provided to the Registry will include the following highly protected information (known as Sensitive PHI)</p>
<ul>
<li>Substance abuse records (including alcoholism)</li>
<li>AIDS or HIV treatment records</li>
<li>Mental health services (does not include psychotherapy notes)</li>
<li>Genetic information</li>
</ul>
<p><strong>By clicking Submit on this Authorization, you authorize GENETWORx to use and share your information in the Registry for medical, research, commercial, marketing or other business purposes including, but not
limited to, those described in the Informed Consent.</strong></p>
<p>This Authorization involves the use of a Registry and will remain in effect until you revoke it.<br>You may change your mind and revoke (take back) the right to use your protected health information at any time. However,
even if you revoke this Authorization, the Registry may still maintain, use or disclose information it has already collected about you. If you revoke this Authorization, GENETWORx will no longer collect new information
about you for the Registry. To revoke this Authorization, you must email <a href="mailto:privacy@recoverycoa.com">privacy@recoverycoa.com</a>.</p>
<p>I understand that information disclosed to the Registry pursuant to this Authorization may be subject to re-disclosure and may no longer be protected by federal and state law.</p>
<p>By clicking Submit, you are voluntarily agreeing to be in this Registry and to the use and disclosure of your protected health information as described above. Your health information is being released to GENETWORx at your
request. You understand that your treatment, payment, enrollment or eligibility for benefits does not depend on whether you click Submit on this Authorization and participate in the Registry.</p>
<p>To manage or change opt in preferences or revoke this Authorization, you must call 844-335-2482.</p>
<p>Upon request, you will be given a signed copy of this Authorization form to keep for your personal records.</p>
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INFORMED CONSENT TO PARTICIPATE IN MEDICAL RECORD REGISTRY
GENETWORx and its affiliates (“We, Us, Our”) are creating a medical record
registry to help Us predict, prevent, and treat disease (the “Registry”). The
Registry matches patients’ laboratory test information with medical history
information obtained from health plans, physicians, health care professionals,
hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and
other medical facilities. We will use data analytics, artificial intelligence
and other automated tools to analyze the data in the Registry for various
purposes including improving Our patient care and outcomes, lowering costs,
recommending products and services to support your health and wellbeing, or
sharing data with other healthcare providers, medical researchers, drug
developers, and clinical trial teams to advance medical science.
SUMMARY OF INFORMATION
* This Informed Consent and Authorization asks for your permission to
participate in the Registry by allowing Us to obtain, store, use and share
your information.
* Participation is voluntary and will not affect your care in any way.
* We may share your de-identified information with third parties without any
further consent or authorization.
* Once collected by Us, your information will be stored with industry standard
security safeguards.
WHAT IS A REGISTRY?
A Registry is a collection of information about people who have various diseases
or conditions, or who receive various tests or treatments. The Registry holds
patient information according to the data security standards of federal and
state law.
This Informed Consent provides you with information that you should know and
understand before agreeing to add your information to the Registry. Please read
this Informed Consent carefully.
WHAT INFORMATION IS BEING COLLECTED FOR THE REGISTRY?
Information (data) will be collected from your health plans, physicians, health
care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy
benefits managers, and other medical facilities. We will collect health,
demographic, claims, billing, pharmacy and medical records. All information will
be collected from your records of the care you have received in the past ten
years, are receiving or will be receiving in the future for so long as you
continue to participate in the Registry.
HOW WILL INFORMATION IN THE REGISTRY BE USED?
The purpose of this Registry is to help Us predict, prevent, and treat disease.
Information in the Registry may be used for medical, research, commercial,
marketing or other business purposes including, but not limited to providing
healthcare or care coordination services, communicating with you about
diagnostic tests, clinical trials or other healthcare related services that may
be of interest based upon your medical history including marketing and promoting
our services and the services of third parties, aggregating and analyzing data
to understand or improve Our testing, treatment services, and operations,
research to predict, prevent and treat disease(s), de-identifying data to create
data sets that will be shared with third parties such as medical researchers and
drug developers to advance medical treatment, for administrative purposes, and
for other legally permissible purposes.
HOW WILL MY HEALTH INFORMATION BE SHARED?
We may share your identifiable information with Our affiliates under common
ownership to use for the same purposes for which We may use your information. We
may also share your information with third party service providers performing
services on our behalf. We may share your information for legal purposes
including as we deem necessary to respond to a subpoena, regulation, binding
order of a data protection agency, legal process, governmental request or other
legal or regulatory process. We may also share your information in business
transfers including in connection with a merger, acquisition, the sale of
company assets, or in any similar transaction, or to the extent as may be
required in the unlikely event of insolvency bankruptcy, or a receivership. Once
your information is de-identified is no longer personal information and can be
used by Us and shared with third parties for any purposes, including sale to
third parties.
HOW LONG IS YOUR PARTICIPATION IN THE REGISTRY?
With your authorization, we will collect your historic and future health
information when you enroll in the Registry. You may stop participating in the
Registry at any time.
WHAT RISKS ARE KNOWN ABOUT BEING IN THE REGISTRY?
We will comply with the applicable HIPAA standards that protect your health and
personal information. However, there is the potential risk your participation in
this Registry may expose your information (including health information) stored
in the Registry.
There may be other risks that are not known at this time.
WHAT BENEFIT CAN YOU EXPECT?
You may receive a benefit from participation in the Registry if We are able to
provide you information about diagnostic tests or clinical studies for which you
may be eligible. For research related purposes, you will not receive any direct
benefit.
WHAT ARE THE FINANCIAL CONSIDERATIONS?
Cost
There will be no cost to you for your participation in this Registry.
Payment for Participation
You will not be paid for your participation in this Registry or for any future
use of the information in the Registry.
VOLUNTARY PARTICIPATION/WITHDRAWAL
Your decision to take part in this Registry is completely voluntary. You are
free to choose not to take part in the Registry and may change your mind and
withdraw at any time. Your relationship with Us and your care through Us (now or
in the future) will not be affected in any way if you withdraw or refuse to
participate. You will not lose any benefits to which you are otherwise entitled.
WHAT IF YOU DECIDE NOT TO GIVE PERMISSION TO USE AND GIVE OUT YOUR INFORMATION?
By clicking Submit on this informed consent form and authorization, you are
giving permission for Us to obtain, use and share your information as described
above. If you refuse to give permission, you are declining to be in this
Registry.
Information that is already in the Registry cannot be removed, deleted or
withdrawn.
QUESTIONS
If you have any additional questions, or if you wish to report a problem that
may be related to this Registry, Our Privacy Officer can be reached by email at
privacy@recoverycoa.com or at 484-803-9655 during business hours.
Do not click Submit on this informed consent form unless you have had a chance
to ask questions and have received satisfactory answers to all your questions.
AGREEMENT TO PARTICIPATE IN REGISTRY AND AUTHORIZATION
To enroll in the GENETWORx Registry, you or your legal representative must click
Submit on this Authorization. By clicking Submit on this page, you are
confirming that you have read the information in the “Informed Consent to
Participate in the Medical Record Registry” document and you are voluntarily
agreeing to be in the Registry.
By clicking Submit on this Authorization, you authorize any health plan,
physician, health care professional, hospital, clinic, laboratory, pharmacy,
pharmacy benefits manager, medical facility, health information exchange, health
information aggregator or other health care provider that has provided payment,
treatment or services to you to release and disclose the following records to
GENETWORx to be incorporated into the Registry:
Any and all information (including personal, health, demographic, claims,
billing, pharmacy and medical records) created in the ten years prior to the
date of this Authorization or at any time after the date of this Authorization
for as long as this Authorization remains in effect.
The records provided to the Registry will include the following highly protected
information (known as Sensitive PHI)
* Substance abuse records (including alcoholism)
* AIDS or HIV treatment records
* Mental health services (does not include psychotherapy notes)
* Genetic information
By clicking Submit on this Authorization, you authorize GENETWORx to use and
share your information in the Registry for medical, research, commercial,
marketing or other business purposes including, but not limited to, those
described in the Informed Consent.
This Authorization involves the use of a Registry and will remain in effect
until you revoke it.
You may change your mind and revoke (take back) the right to use your protected
health information at any time. However, even if you revoke this Authorization,
the Registry may still maintain, use or disclose information it has already
collected about you. If you revoke this Authorization, GENETWORx will no longer
collect new information about you for the Registry. To revoke this
Authorization, you must email privacy@recoverycoa.com.
I understand that information disclosed to the Registry pursuant to this
Authorization may be subject to re-disclosure and may no longer be protected by
federal and state law.
By clicking Submit, you are voluntarily agreeing to be in this Registry and to
the use and disclosure of your protected health information as described above.
Your health information is being released to GENETWORx at your request. You
understand that your treatment, payment, enrollment or eligibility for benefits
does not depend on whether you click Submit on this Authorization and
participate in the Registry.
To manage or change opt in preferences or revoke this Authorization, you must
call 844-335-2482.
Upon request, you will be given a signed copy of this Authorization form to keep
for your personal records.
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information may be shared with RCA and affiliated companies, who may contact you
to keep you updated with important health-related information.
By entering your mobile number and clicking Submit, you also consent that RCA
and affiliated companies may send you SMS messages using autodialing technology
from our primary messaging code 73529 for health-related information and as
described in our terms of use in our privacy policy. Std. msg & data rates
apply. Reply HELP or help, STOP to cancel. Msg freq may vary.Your consent is not
required as a condition of purchasing any product, good, or service.
INFORMED CONSENT TO PARTICIPATE IN MEDICAL RECORD REGISTRY
GENETWORx and its affiliates (“We, Us, Our”) are creating a medical record
registry to help Us predict, prevent, and treat disease (the “Registry”). The
Registry matches patients’ laboratory test information with medical history
information obtained from health plans, physicians, health care professionals,
hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and
other medical facilities. We will use data analytics, artificial intelligence
and other automated tools to analyze the data in the Registry for various
purposes including improving Our patient care and outcomes, lowering costs,
recommending products and services to support your health and wellbeing, or
sharing data with other healthcare providers, medical researchers, drug
developers, and clinical trial teams to advance medical science.
SUMMARY OF INFORMATION
* This Informed Consent and Authorization asks for your permission to
participate in the Registry by allowing Us to obtain, store, use and share
your information.
* Participation is voluntary and will not affect your care in any way.
* We may share your de-identified information with third parties without any
further consent or authorization.
* Once collected by Us, your information will be stored with industry standard
security safeguards.
WHAT IS A REGISTRY?
A Registry is a collection of information about people who have various diseases
or conditions, or who receive various tests or treatments. The Registry holds
patient information according to the data security standards of federal and
state law.
This Informed Consent provides you with information that you should know and
understand before agreeing to add your information to the Registry. Please read
this Informed Consent carefully.
WHAT INFORMATION IS BEING COLLECTED FOR THE REGISTRY?
Information (data) will be collected from your health plans, physicians, health
care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy
benefits managers, and other medical facilities. We will collect health,
demographic, claims, billing, pharmacy and medical records. All information will
be collected from your records of the care you have received in the past ten
years, are receiving or will be receiving in the future for so long as you
continue to participate in the Registry.
HOW WILL INFORMATION IN THE REGISTRY BE USED?
The purpose of this Registry is to help Us predict, prevent, and treat disease.
Information in the Registry may be used for medical, research, commercial,
marketing or other business purposes including, but not limited to providing
healthcare or care coordination services, communicating with you about
diagnostic tests, clinical trials or other healthcare related services that may
be of interest based upon your medical history including marketing and promoting
our services and the services of third parties, aggregating and analyzing data
to understand or improve Our testing, treatment services, and operations,
research to predict, prevent and treat disease(s), de-identifying data to create
data sets that will be shared with third parties such as medical researchers and
drug developers to advance medical treatment, for administrative purposes, and
for other legally permissible purposes.
HOW WILL MY HEALTH INFORMATION BE SHARED?
We may share your identifiable information with Our affiliates under common
ownership to use for the same purposes for which We may use your information. We
may also share your information with third party service providers performing
services on our behalf. We may share your information for legal purposes
including as we deem necessary to respond to a subpoena, regulation, binding
order of a data protection agency, legal process, governmental request or other
legal or regulatory process. We may also share your information in business
transfers including in connection with a merger, acquisition, the sale of
company assets, or in any similar transaction, or to the extent as may be
required in the unlikely event of insolvency bankruptcy, or a receivership. Once
your information is de-identified is no longer personal information and can be
used by Us and shared with third parties for any purposes, including sale to
third parties.
HOW LONG IS YOUR PARTICIPATION IN THE REGISTRY?
With your authorization, we will collect your historic and future health
information when you enroll in the Registry. You may stop participating in the
Registry at any time.
WHAT RISKS ARE KNOWN ABOUT BEING IN THE REGISTRY?
We will comply with the applicable HIPAA standards that protect your health and
personal information. However, there is the potential risk your participation in
this Registry may expose your information (including health information) stored
in the Registry.
There may be other risks that are not known at this time.
WHAT BENEFIT CAN YOU EXPECT?
You may receive a benefit from participation in the Registry if We are able to
provide you information about diagnostic tests or clinical studies for which you
may be eligible. For research related purposes, you will not receive any direct
benefit.
WHAT ARE THE FINANCIAL CONSIDERATIONS?
Cost
There will be no cost to you for your participation in this Registry.
Payment for Participation
You will not be paid for your participation in this Registry or for any future
use of the information in the Registry.
VOLUNTARY PARTICIPATION/WITHDRAWAL
Your decision to take part in this Registry is completely voluntary. You are
free to choose not to take part in the Registry and may change your mind and
withdraw at any time. Your relationship with Us and your care through Us (now or
in the future) will not be affected in any way if you withdraw or refuse to
participate. You will not lose any benefits to which you are otherwise entitled.
WHAT IF YOU DECIDE NOT TO GIVE PERMISSION TO USE AND GIVE OUT YOUR INFORMATION?
By clicking Submit on this informed consent form and authorization, you are
giving permission for Us to obtain, use and share your information as described
above. If you refuse to give permission, you are declining to be in this
Registry.
Information that is already in the Registry cannot be removed, deleted or
withdrawn.
QUESTIONS
If you have any additional questions, or if you wish to report a problem that
may be related to this Registry, Our Privacy Officer can be reached by email at
privacy@recoverycoa.com or at 484-803-9655 during business hours.
Do not click Submit on this informed consent form unless you have had a chance
to ask questions and have received satisfactory answers to all your questions.
AGREEMENT TO PARTICIPATE IN REGISTRY AND AUTHORIZATION
To enroll in the GENETWORx Registry, you or your legal representative must click
Submit on this Authorization. By clicking Submit on this page, you are
confirming that you have read the information in the “Informed Consent to
Participate in the Medical Record Registry” document and you are voluntarily
agreeing to be in the Registry.
By clicking Submit on this Authorization, you authorize any health plan,
physician, health care professional, hospital, clinic, laboratory, pharmacy,
pharmacy benefits manager, medical facility, health information exchange, health
information aggregator or other health care provider that has provided payment,
treatment or services to you to release and disclose the following records to
GENETWORx to be incorporated into the Registry:
Any and all information (including personal, health, demographic, claims,
billing, pharmacy and medical records) created in the ten years prior to the
date of this Authorization or at any time after the date of this Authorization
for as long as this Authorization remains in effect.
The records provided to the Registry will include the following highly protected
information (known as Sensitive PHI)
* Substance abuse records (including alcoholism)
* AIDS or HIV treatment records
* Mental health services (does not include psychotherapy notes)
* Genetic information
By clicking Submit on this Authorization, you authorize GENETWORx to use and
share your information in the Registry for medical, research, commercial,
marketing or other business purposes including, but not limited to, those
described in the Informed Consent.
This Authorization involves the use of a Registry and will remain in effect
until you revoke it.
You may change your mind and revoke (take back) the right to use your protected
health information at any time. However, even if you revoke this Authorization,
the Registry may still maintain, use or disclose information it has already
collected about you. If you revoke this Authorization, GENETWORx will no longer
collect new information about you for the Registry. To revoke this
Authorization, you must email privacy@recoverycoa.com.
I understand that information disclosed to the Registry pursuant to this
Authorization may be subject to re-disclosure and may no longer be protected by
federal and state law.
By clicking Submit, you are voluntarily agreeing to be in this Registry and to
the use and disclosure of your protected health information as described above.
Your health information is being released to GENETWORx at your request. You
understand that your treatment, payment, enrollment or eligibility for benefits
does not depend on whether you click Submit on this Authorization and
participate in the Registry.
To manage or change opt in preferences or revoke this Authorization, you must
call 844-335-2482.
Upon request, you will be given a signed copy of this Authorization form to keep
for your personal records.
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Your privacy is important to us. By clicking Submit, you confirm that you have
reviewed our privacy policy and agree to our terms of use and that your
information may be shared with RCA and affiliated companies, who may contact you
to keep you updated with important health-related information.
By entering your mobile number and clicking Submit, you also consent that RCA
and affiliated companies may send you SMS messages using autodialing technology
from our primary messaging code 73529 for health-related information and as
described in our terms of use in our privacy policy. Std. msg & data rates
apply. Reply HELP or help, STOP to cancel. Msg freq may vary.Your consent is not
required as a condition of purchasing any product, good, or service.
INFORMED CONSENT TO PARTICIPATE IN MEDICAL RECORD REGISTRY
GENETWORx and its affiliates (“We, Us, Our”) are creating a medical record
registry to help Us predict, prevent, and treat disease (the “Registry”). The
Registry matches patients’ laboratory test information with medical history
information obtained from health plans, physicians, health care professionals,
hospitals, clinics, laboratories, pharmacies, pharmacy benefits managers, and
other medical facilities. We will use data analytics, artificial intelligence
and other automated tools to analyze the data in the Registry for various
purposes including improving Our patient care and outcomes, lowering costs,
recommending products and services to support your health and wellbeing, or
sharing data with other healthcare providers, medical researchers, drug
developers, and clinical trial teams to advance medical science.
SUMMARY OF INFORMATION
* This Informed Consent and Authorization asks for your permission to
participate in the Registry by allowing Us to obtain, store, use and share
your information.
* Participation is voluntary and will not affect your care in any way.
* We may share your de-identified information with third parties without any
further consent or authorization.
* Once collected by Us, your information will be stored with industry standard
security safeguards.
WHAT IS A REGISTRY?
A Registry is a collection of information about people who have various diseases
or conditions, or who receive various tests or treatments. The Registry holds
patient information according to the data security standards of federal and
state law.
This Informed Consent provides you with information that you should know and
understand before agreeing to add your information to the Registry. Please read
this Informed Consent carefully.
WHAT INFORMATION IS BEING COLLECTED FOR THE REGISTRY?
Information (data) will be collected from your health plans, physicians, health
care professionals, hospitals, clinics, laboratories, pharmacies, pharmacy
benefits managers, and other medical facilities. We will collect health,
demographic, claims, billing, pharmacy and medical records. All information will
be collected from your records of the care you have received in the past ten
years, are receiving or will be receiving in the future for so long as you
continue to participate in the Registry.
HOW WILL INFORMATION IN THE REGISTRY BE USED?
The purpose of this Registry is to help Us predict, prevent, and treat disease.
Information in the Registry may be used for medical, research, commercial,
marketing or other business purposes including, but not limited to providing
healthcare or care coordination services, communicating with you about
diagnostic tests, clinical trials or other healthcare related services that may
be of interest based upon your medical history including marketing and promoting
our services and the services of third parties, aggregating and analyzing data
to understand or improve Our testing, treatment services, and operations,
research to predict, prevent and treat disease(s), de-identifying data to create
data sets that will be shared with third parties such as medical researchers and
drug developers to advance medical treatment, for administrative purposes, and
for other legally permissible purposes.
HOW WILL MY HEALTH INFORMATION BE SHARED?
We may share your identifiable information with Our affiliates under common
ownership to use for the same purposes for which We may use your information. We
may also share your information with third party service providers performing
services on our behalf. We may share your information for legal purposes
including as we deem necessary to respond to a subpoena, regulation, binding
order of a data protection agency, legal process, governmental request or other
legal or regulatory process. We may also share your information in business
transfers including in connection with a merger, acquisition, the sale of
company assets, or in any similar transaction, or to the extent as may be
required in the unlikely event of insolvency bankruptcy, or a receivership. Once
your information is de-identified is no longer personal information and can be
used by Us and shared with third parties for any purposes, including sale to
third parties.
HOW LONG IS YOUR PARTICIPATION IN THE REGISTRY?
With your authorization, we will collect your historic and future health
information when you enroll in the Registry. You may stop participating in the
Registry at any time.
WHAT RISKS ARE KNOWN ABOUT BEING IN THE REGISTRY?
We will comply with the applicable HIPAA standards that protect your health and
personal information. However, there is the potential risk your participation in
this Registry may expose your information (including health information) stored
in the Registry.
There may be other risks that are not known at this time.
WHAT BENEFIT CAN YOU EXPECT?
You may receive a benefit from participation in the Registry if We are able to
provide you information about diagnostic tests or clinical studies for which you
may be eligible. For research related purposes, you will not receive any direct
benefit.
WHAT ARE THE FINANCIAL CONSIDERATIONS?
Cost
There will be no cost to you for your participation in this Registry.
Payment for Participation
You will not be paid for your participation in this Registry or for any future
use of the information in the Registry.
VOLUNTARY PARTICIPATION/WITHDRAWAL
Your decision to take part in this Registry is completely voluntary. You are
free to choose not to take part in the Registry and may change your mind and
withdraw at any time. Your relationship with Us and your care through Us (now or
in the future) will not be affected in any way if you withdraw or refuse to
participate. You will not lose any benefits to which you are otherwise entitled.
WHAT IF YOU DECIDE NOT TO GIVE PERMISSION TO USE AND GIVE OUT YOUR INFORMATION?
By clicking Submit on this informed consent form and authorization, you are
giving permission for Us to obtain, use and share your information as described
above. If you refuse to give permission, you are declining to be in this
Registry.
Information that is already in the Registry cannot be removed, deleted or
withdrawn.
QUESTIONS
If you have any additional questions, or if you wish to report a problem that
may be related to this Registry, Our Privacy Officer can be reached by email at
privacy@recoverycoa.com or at 484-803-9655 during business hours.
Do not click Submit on this informed consent form unless you have had a chance
to ask questions and have received satisfactory answers to all your questions.
AGREEMENT TO PARTICIPATE IN REGISTRY AND AUTHORIZATION
To enroll in the GENETWORx Registry, you or your legal representative must click
Submit on this Authorization. By clicking Submit on this page, you are
confirming that you have read the information in the “Informed Consent to
Participate in the Medical Record Registry” document and you are voluntarily
agreeing to be in the Registry.
By clicking Submit on this Authorization, you authorize any health plan,
physician, health care professional, hospital, clinic, laboratory, pharmacy,
pharmacy benefits manager, medical facility, health information exchange, health
information aggregator or other health care provider that has provided payment,
treatment or services to you to release and disclose the following records to
GENETWORx to be incorporated into the Registry:
Any and all information (including personal, health, demographic, claims,
billing, pharmacy and medical records) created in the ten years prior to the
date of this Authorization or at any time after the date of this Authorization
for as long as this Authorization remains in effect.
The records provided to the Registry will include the following highly protected
information (known as Sensitive PHI)
* Substance abuse records (including alcoholism)
* AIDS or HIV treatment records
* Mental health services (does not include psychotherapy notes)
* Genetic information
By clicking Submit on this Authorization, you authorize GENETWORx to use and
share your information in the Registry for medical, research, commercial,
marketing or other business purposes including, but not limited to, those
described in the Informed Consent.
This Authorization involves the use of a Registry and will remain in effect
until you revoke it.
You may change your mind and revoke (take back) the right to use your protected
health information at any time. However, even if you revoke this Authorization,
the Registry may still maintain, use or disclose information it has already
collected about you. If you revoke this Authorization, GENETWORx will no longer
collect new information about you for the Registry. To revoke this
Authorization, you must email privacy@recoverycoa.com.
I understand that information disclosed to the Registry pursuant to this
Authorization may be subject to re-disclosure and may no longer be protected by
federal and state law.
By clicking Submit, you are voluntarily agreeing to be in this Registry and to
the use and disclosure of your protected health information as described above.
Your health information is being released to GENETWORx at your request. You
understand that your treatment, payment, enrollment or eligibility for benefits
does not depend on whether you click Submit on this Authorization and
participate in the Registry.
To manage or change opt in preferences or revoke this Authorization, you must
call 844-335-2482.
Upon request, you will be given a signed copy of this Authorization form to keep
for your personal records.
If you are a human seeing this field, please leave it empty.
(866) 932-0109
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