I hereby authorize the provider performing the collection procedure for my blood and/or blood derived samples to disclose my protected health information to RapidTestMe, LLC. The only protected health information that my provider may disclose to RapidTestMe, LLC is that which is reasonably related to the receipt, testing, processing, cryopreservation, storage, and eventual release of my blood and/or blood-derived samples by RapidTestMe, LLC. The purpose of this disclosure is to allow RapidTestMe, LLC to have the information necessary to provide these services. 

I hereby authorize RapidTestMe, LLC to disclose my protected health information to the provider performing my collection procedure and to other third party contractors. The only protected health information that RapidTestMe, LLC may disclose to my provider or to such contractors is that which is reasonably related to the collection and storage of my samples. The purpose of this disclosure is to allow my provider and the relevant contractors to have the information necessary to collect, process, and/or store my samples. 

I understand that the information used or disclosed to RapidTestMe, LLC or my provider may be subject to re-disclosure and may then no longer be protected by federal privacy regulations. 

I may revoke the authorization permitting my provider to disclose my information to RapidTestMe, LLC by notifying my provider in writing of my desire to revoke it. However, I understand that any action already taken by my provider or RapidTestMe, LLC reliance on this authorization cannot be reversed, and my revocation will not affect those actions. 

This authorization is in perpetuity after the date of signature below. I acknowledge and agree that RapidTestMe, LLC and its relevant contractors may retain my protected health information as long as they retain or store any of my samples. 

I understand that my authorization is voluntary and I am not required to sign this form. My failure to sign this form will not otherwise affect my medical treatment. However, I further understand that my provider will not remove any blood, and RapidTestMe, LLC cannot process or store my samples, without this authorization. 

I have read and understand the above information. I am either the patient or am authorized to act on behalf of the patient to sign this document, thus verifying authorization for the use or disclosure of the protected health information under the above stated terms.