United Terms & Conditions
UNITED TERMS AND CONDITIONS
Revised December 17,2020
By participating in the COVID-19 testing, you consent to the collection of a body fluid specimen. You also consent to the collection of data related to a history of symptoms related to COVID-19.
Protections from Disclosure of Medical Information: Advanced Diagnostic Laboratory agrees to abide by all applicable laws and regulations governing the privacy and security of your personal health information. To the extent Advanced Diagnostic Laboratory is subject to the Health Insurance Portability and Accountability Act and its implementing regulations (“HIPAA”), Advanced Diagnostics Laboratory will abide by HIPAA and maintain the privacy and security of your Protected Health Information (“PHI”) in accordance with its Notice of Privacy Practices (“Notice”), which is available on the Advanced Diagnostic Laboratory website, and subject to this COVID-19 Viral Testing Notice and Consent. You may also request a copy of the Notice from Advanced Diagnostic Laboratory at any time.
Authorization. I authorize Advanced Diagnostic Laboratory, to collect, use, disclose, and receive information about me for purposes of performing COVID-19 testing and related services. I understand and agree that information may include, but not be limited to, general demographic information, history of symptoms and contacts with others who may have had symptoms or been exposed to COVID-19, and nasal swab specimens. I understand and agree that a record of my appointment for and participation in this COVID-19 testing may be provided to United and my results of this COVID-19 testing may be disclosed, in detail, to United. I further understand and agree that United will use this information for the purpose of supporting the safety of its flights and as otherwise described in any notice made available to me by United and that United may disclose this information to designated staff and third parties providing services on behalf of United, as necessary for the purposes described above, and to other third parties, such as the CDC or TSA, as necessary to comply with law.
Effective Time. Expiration date will be three (3) years from date of signature.
Right to Revoke Authorization. I understand that I may revoke this authorization at any time by submitting notice of my revocation in writing to Health Center or Advanced Diagnostic Laboratory, Compliance Department, 1077 Central Parkway South, Suite 200, San Antonio, TX 78232. I understand that prior actions taken in reliance on this authorization by entities that had permission to access my information will not be affected. As such, I understand that my information, including my COVID-19 test results, will be shared by Advanced Diagnostic Laboratory with United regardless of whether I change my flight, and such information will be retained by United for use in accordance with the purposes described above.
Signature Authorization. I have read this COVID-19 Viral Testing Notice and Consent in its entirety and voluntarily consent to the COVID-19 testing. I agree to the uses and disclosures of the information as described above. I understand that revoking this authorization does not stop disclosure of my information that has occurred prior to a revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures as provided by HIPAA, 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
I sign this agreement truthfully, knowingly, freely, and voluntarily. I acknowledge that the person executing this agreement is the person participating in COVID-19 testing, or such participant’s legal representative, and is authorized to act on such person’s behalf to sign this agreement. The participant or legal representative is at least 18 years old.