Pursuant to the terms of this authorization, I hereby voluntarily authorize the CLIA-certified laboratory performing testing on my biological sample to disclose my test results and personal information to:

imaware^tm Inc. (“imaware”)
106 E 6^th Street, Suite 900-114
Austin, TX 78701

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And:

My employer and any entity or organization that arranged my laboratory testing.

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The information to be disclosed from my health record is the results of the laboratory testing provided through the imaware platform. imaware operates an online portal through which my laboratory test results are made available for viewing. The purpose of disclosing my test results to imaware pursuant to this authorization is to permit the operation of this portal to allow my employer and the entities described above to view my test results.  The purpose of disclosing my test results to my employer and other entities is to permit the use of my test results in accordance with their testing policies, which I acknowledge have been provided to me separately.  I further acknowledge that I have read and understand those testing policies and have had the opportunity to discuss any questions.  I understand that I may revoke this authorization in a writing submitted at any time to imaware, except to the extent that action has been taken in reliance on this authorization.  If this authorization has not been revoked, it will terminate seven (7) years from the date I sign this authorization.I understand that signing this authorization is voluntary, but my refusal to sign this authorization may result in my inability to receive laboratory testing arranged by my employer or another third party because such testing is being administered solely for the purpose for creating protected health information for the benefit of my employer and/or the third party arranging testing. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164] or the Privacy Act of 1974 [5 USC § 552a].I understand that I have a right to print and/or receive a copy of this authorization.By signing this authorization, I consent and agree that:

• I am the individual whose records will be released.
• I am 18 years of age or older.
• I have read this authorization or have had the form read to me, and I understand its contents.
• I am the parent, legal guardian, or person acting in loco parentis of the individual whose records will be released.
• I have read this authorization or have had the form read to me, and I understand its contents.

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