Authorization To Disclose



InHouse Physicians, P.C. (“IHP”) has provided use of IHP’s digital platform (“Platform”) as a mechanism to allow you to share your demographic information, COVID-19 test results, and/or COVID-19 vaccination status, and/or daily health screening clearance with your organizer, sponsor, organization, employer, or school (collectively, the “Sponsor”). This information is only shared with your Sponsor if you submitted and/or uploaded to this Platform. Your utilization of the Platform to allow your Sponsor access to your information is voluntary and is not required by IHP. Your utilization of the Platform and sharing of information on the Platform is not considered to be a covered transaction under HIPAA because IHP is not acting as your health care provider solely by your use of the Platform. However, IHP respects the privacy of your information and will only disclose information to your Sponsor if the following HIPAA compliance authorization is agreed to by you:


1. By signing below, I hereby authorize the following health information to be disclosed:

My name, contact information, and any other information that I upload to the Platform.

Any information related to COVID-19 test results that I upload to the Platform including, but not limited to, the results of any COVID-19 test results.

Any information related to my receipt of a COVID-19 vaccination that I upload to the Platform including, but not limited to, my vaccination status and vaccination record card.

Any information related to my digital health screening clearance that I submit to the Platform.


2. The person or group of people who are authorized to disclose my information listed above is: InHouse Physicians, S.C. (IHP).


3. I hereby authorize IHP to disclose my information listed above to my Sponsor that utilizes the Platform.


4. This authorization will expire four (4) weeks from the end of this event unless earlier terminated or revoked by me as provided herein.


5. The purpose of this disclosure is to allow my Sponsor to have access to the information listed in Section 1.


6. I understand that I have the right to revoke this Authorization, if the revocation is in writing, at any time by sending a written request to IHP. I am aware that my revocation will not be effective regarding the uses and disclosures of content by IHP made in reliance on this Authorization and that have been made prior to receipt of my revocation.


7. I understand that IHP may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.


8. I understand that my information that is disclosed under this Authorization may be subject to re-disclosure by the recipient, and the privacy of my information will no longer be protected by the law.


9. I understand that if I am able to access a copy of this Authorization at any time by contacting IHP at ihpcontactus@gmail.com


By signing this Authorization, I acknowledge that I have read and understand this Authorization. Further, I authorize the disclosure of the information set forth herein in accordance with the terms of this Authorization.

Use your mouse or finger to draw your signature above
Date/Time*
:  

Registration & COVID-19 Vaccine Record Upload

Vaccination Record Upload

Please upload your COVID-19 vaccination record.
Type of Vaccine

Each attendee must create their own registration to receive an email stating the submission has been verified.

Name*
Date of Birth (mm-dd-yyyy)*
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

IHP Consent, Terms, and Conditions

The following terms and conditions (the “Agreement”) constitute your agreement regarding use of InHouse Physicians, P.C.'s (“IHP”) digital platform ("Platform") and services related to COVID-19 testing, vaccination, and screening ("Services").


1. Permitted Uses of Platform

Use of this Platform is allowed only by strict adherence to this Agreement. The Platform may only be used for the purposes of (a) registration and consent for receiving and/or paying for a COVID-19 test and/ or other COVID-19 related services, (b) submitting accurate and applicable answers to the digital health screening; (c) uploading COVID-19 vaccine records; and/or (d) uploading the results of your self-administered COVID-19 test (collectively, the “Permitted Use”). The Platform may not be used for any other purposes except for the Permitted Use and cannot be used for emergency medical needs.  The Platform may only be used in compliance with all applicable laws and to access information that you are permitted to access.  Your use of the Platform may be blocked if you violate the terms of this Agreement or do not use the Platform for the Permitted Use as permitted by this Agreement.

 

2. Consent for Testing & Treatment

This consent represents an informed consent by you to receive COVID-19 testing services and other COVID-19 related services to the extent provided by IHP or its contractors. I have been informed about the purpose of COVID-19 testing and screening, procedures, possible benefits and risks, any other services provided by IHP to me. If I have any questions about COVID-19 testing and screening or other services provided by IHP, I acknowledge that I can call IHP at 1-800-356-3627.


3. Disclosure of COVID-19 Test Results and Vaccination Status

 You acknowledge and agree that you have been given an opportunity to review a copy of IHP's Notice of Privacy Practices. You also acknowledge and agree that the results of any COVID-19 test, vaccination, or screening status may be disclosed by IHP to your sponsor, organization, employer, or school (collectively, the “Sponsor”), if you have filled out the IHP HIPAA Authorization. You further acknowledge and agree that any COVID-19 test results may be shared with federal, state, and or local authorities if required by law.  


4. COVID-19 Test Procedures, Submission, and Results 

 As it relates to the COVID-19 test, you acknowledge and agree that you have followed all instructions for the COVID-19 test as outlined by the manufacturer. You acknowledge and agree that the test results you are uploading are your test results and not that of any other individual. You acknowledge and agree that if you have any questions about COVID-19 or your test results, you will seek treatment from or consult with your medical provider. IHP will not diagnose you with any medical conditions or illnesses, including COVID-19, and any diagnosis results solely from your utilization of the COVID-19 test provided by a third party. IHP shall also not be liable for any inability to supply COVID-19 tests for any reason, including manufacturer shortages or delays. More information about COVID-19 Testing can be found on the CDC website


5. Payment & Shipping Terms & Conditions 

Your sponsor or employer (the “Sponsor”) requires that you pay for your COVID-19 test and any related professional services, such as laboratory fees.   Please make payment utilizing the Platform below and upon receipt of payment and the Platforms referenced herein IHP will administer a COVID-19 test to you prior to or during the meeting or event.  IHP will not be submitting a claim to your insurance carrier for the payment of your COVID-19 test.  All payments made are non-refundable. 

 After your test is administered, IHP will send the sample to a laboratory for processing.  Neither IHP nor your Sponsor is responsible for any delays or damage to the sample while it is being shipped to the laboratory or any delays in the laboratory processing the sample.  Due to the sensitivity of the test, delays in shipping the sample may result in the voidance of your sample. 


6. COVID-19 Vaccination Status and Records

  CDC COVID-19 Vaccination Record Cards are official federal documents issued by the Centers for Disease Control. It is ILLEGAL to upload, provide, present, utter, or otherwise use a falsified CDC COVID-19 Vaccination Record Card. A CDC COVID-19 Vaccination Record Card is falsified: If the person uploading, providing, presenting, uttering or otherwise using the card did not receive the vaccination(s) as stated on the card; or if the person uploading, providing, presenting, uttering, or otherwise using the card, is an adult who is uploading, providing, presenting, uttering, or otherwise using the card on behalf of a minor, and the minor has not received the vaccination(s) as stated on the card. You understand that if you falsify a COVID-19 Vaccination Record Card you may be subject to prosecution for federal or state offenses. As it relates to the COVID-19 vaccination status, you acknowledge and agree that you have uploaded your individual COVID-19 vaccination status by submitting proof of vaccination. The proof of vaccination that was submitted by you is the proof of vaccination provided to you by the health care provider that administered the COVID-19 test and has not been falsified or tampered with in any manner whatsoever. You acknowledge and agree that IHP is not liable for and that you will release, defend, and indemnify IHP from any claims or causes of action relating to any false or fraudulent COVID-19 test results or vaccination status. More information about the COVID-19 Vaccine can be found on the CDC website.


7. COVID-19 Risks and Warnings 

 You acknowledge and agree that COVID-19 is highly contagious and is spread by person-to-person contact, and as a result, federal and state health agencies recommend social distancing. You further acknowledge and agree that regardless of your COVID-19 test results or vaccination status, you may contract the COVID-19 virus. More about COVID-19 can be found at the CDC website. You further acknowledge and agree that IHP has no responsibility or liability as it relates to your exposure to or contracting of COVID-19 in the workplace, at an event, or at any other function that may be sponsored by, organized by, or hosted by your Sponsor or any other individual or entity.


8. Medical Advice 

You acknowledge and agree that if you are solely uploading and providing your vaccination record card(s) and related demographic information, IHP is not providing you any individualized medical advice or recommendations relating to COVID-19, COVID-19 testing, or the COVID-19 vaccine and that you will seek treatment from your medical provider of choice for any issues, questions, or concerns related to the foregoing. By using the Platform alone, you are not creating any professional-patient relationship with IHP and the use of the Platform is not a substitute for healthcare.


9. IHP’s Intellectual Property

 You may not reproduce, distribute, display or transfer any portion of the Platform or content on the Platform for any commercial purpose. You may only print, download and store information from the Platform in compliance with all laws and in compliance with the Permitted Use. You acknowledge and agree that the Platform is protected by United States and international copyright, trademark, trade secret and other intellectual property rights. You may not copy, decompile, reverse engineer, disassemble or create derivative works of the Platform, or any part thereof.


10. Limitation of Liability, Release, and Indemnification 

The Platform and the Services provided by IHP are provided on an “AS IS” and “AS AVAILABLE” basis, without any warranties of any kind, either express or implied. IHP makes no express or implied warranties about the Platform or Services. To the maximum extent permitted by law, IHP hereby disclaims all such warranties, including all statutory warranties, with respect to the Platform and the Services, including without limitation any warranties that the Platform or the Services are merchantable, of satisfactory quality, accurate, or fit for a particular purpose. IHP does not guarantee that results may be obtained from the Platform. IHP is not responsible for the accuracy, reliability, timeliness, or completeness of information provided by users of the Platform or any other data or information provided or received through the Platform.

You agree that IHP shall not be liable for (a) any losses or damages arising from your use of the Platform; (b) any losses or damages related to the results of your COVID-19 test; (c) and losses or damages related to or arising from your workplace or events or functions sponsored or hosted by the Sponsor; or (d) any economic, incidental, consequential, indirect, special or punitive damages of any kind under any legal theory. You agree to hold harmless, release, defend, and indemnify IHP from all liabilities, losses, and damages, including reasonable attorneys’ fees related to your use of the Platform or the Services. The foregoing indemnification obligation does not apply to liabilities, losses, and damages arising solely from the intentional misconduct or gross negligence of IHP.

No action arising under or in connection with this Agreement or your use of the Platform may be brought by you more than one (1) year after the claim or cause of action arose.


11. Miscellaneous

 If any part of this Agreement is found to be unenforceable, illegal, or invalid, the remaining provisions of this Agreement shall remain unimpaired and enforceable. The headings utilized in this Agreement are for convenience only and in no way limit, define, modify, or describe the meaning, scope, or intent of this Agreement or any terms or conditions therein. These terms may be revised and updated from time to time. All changes are effective immediately when posted to the Platform. Your continued use of the Platform following the posting of a revised Agreement means that you agree and accept all changes. This Agreement and performance under it shall be governed by and construed in accordance with the laws of State of Illinois without regard to its choice of law principles.  You hereby submit and consent to the exclusive jurisdiction of any federal court located within the State of Illinois, assuming such court agrees to federal jurisdiction (otherwise, any state court located within the State of Illinois) as it relates to any disputes, lawsuits, claims, or causes of action related to this Agreement, the Platform, or the Services.

 

Effective Date: October 6, 2021. I acknowledge and agree that I have read the Agreement and agree to all terms contained therein.

By signing below, you hereby acknowledge that you have read, understand, and agree to the IHP's terms and conditions with the intent to be bound hereby.

Use your mouse or finger to draw your signature above
Date Signed*

Confirmation

Attendee has submitted a valid vaccination record.*