ALLRANGEKIT HIPAA AUTHORIZATION AND TELEHEALTH CONSENT

Last Updated: July 23, 2025

This document contains important information about how your health information will be used and disclosed, and about telehealth services that may be provided to you. Please read it carefully.

SECTION 1: HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

1. AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

By accepting this authorization, I authorize AllrangeKit™ and its affiliates, partners, healthcare providers, and service providers to use and disclose my protected health information ("PHI") as described in this authorization.

2. INFORMATION TO BE USED AND DISCLOSED

The health information that may be used and disclosed includes, but is not limited to:

Demographic information (name, date of birth, contact information)
Health history and questionnaire responses
Laboratory test orders and requisitions
Test results and reports for any tests including but not limited to:

Sexually Transmitted Infection (STI) testing
Human Papillomavirus (HPV) testing
Gastrointestinal (GI) tract testing
Urinary Tract Infection (UTI) testing
Any other wellness or diagnostic tests offered through AllrangeKit™

Biological samples and specimen information
Communications with healthcare providers
Billing and payment information related to health services
Clinical notes and interpretations
Treatment recommendations and referrals

3. PARTIES AUTHORIZED TO USE AND DISCLOSE INFORMATION

I understand that my health information may be used and disclosed by:

AllrangeKit™ and its employees
Independent healthcare providers reviewing and authorizing tests
CLIA-certified laboratories performing test analysis
Healthcare providers delivering telehealth services
Third-party service providers supporting our operations
Pharmacy partners (if medications are prescribed)

4. PARTIES WHO MAY RECEIVE INFORMATION

My health information may be disclosed to:

Me or my authorized representatives
Healthcare providers involved in my care (at my request)
Laboratories performing testing services
Healthcare providers I designate to receive my results
Public health authorities as required by law
Other parties as required by law or court order

5. PURPOSE OF USE AND DISCLOSURE

My health information will be used and disclosed for:

Processing and authorizing laboratory test orders
Performing laboratory analysis
Delivering test results
Providing clinical consultations and telehealth services
Treatment recommendations and care coordination
Billing and payment processing
Quality improvement and patient safety activities
Communicating with me about my health and services
Complying with legal and regulatory requirements
Research purposes (only in de-identified form)

6. EXPIRATION

This authorization will remain in effect:

For as long as I maintain an active account with AllrangeKit™
Until I revoke it in writing
For records retention periods required by law

7. RIGHT TO REVOKE

I understand that I have the right to revoke this authorization at any time by submitting a written request to:

📧 Email: support@allrangekit.com

📍 Mail: OPEN Healthcare, 1487 W 178th St., Gardena, CA 90248

ATTN: AllrangeKit™ Privacy Practice

I understand that revocation will not affect actions taken before receipt of my revocation and that I may not be able to receive certain services if I revoke this authorization.

8. RE-DISCLOSURE RISKS

I understand that once my health information is disclosed pursuant to this authorization, it may no longer be protected by federal privacy laws and could be re-disclosed by the recipient.

9. REFUSAL TO SIGN

I understand that I may refuse to sign this authorization, but if I do not sign, I will not be able to receive AllrangeKit™'s services, as the authorization is necessary for the provision of laboratory testing and related healthcare services.

10. COPY OF AUTHORIZATION

I am entitled to receive a copy of this authorization.

SECTION 2: TELEHEALTH SERVICES CONSENT

1. NATURE OF TELEHEALTH SERVICES

I understand that telehealth involves the use of electronic communications to enable healthcare providers to provide clinical services remotely. This may include:

Video consultations
Phone consultations
Secure messaging
Asynchronous communications
Review and interpretation of test results
Treatment recommendations
Prescription services when appropriate

2. TELEHEALTH SERVICES OFFERED

AllrangeKit™ may provide telehealth services related to:

Pre-test consultations and test authorization
Review of health questionnaires
Test result delivery and interpretation
Abnormal result consultations
Treatment recommendations
Prescription of medications when clinically appropriate
Referrals to in-person care when necessary
Follow-up care related to test results

3. TECHNOLOGY REQUIREMENTS

I understand that I will need:

A device with internet connectivity
A working camera and microphone (for video visits)
A private location for consultations
Updated web browser or mobile application

4. POTENTIAL BENEFITS

Improved access to healthcare services
Convenience and reduced travel time
Timely access to test results and consultations
Continuity of care
Access to specialists not available locally

5. POTENTIAL RISKS AND LIMITATIONS

I understand that telehealth has limitations including:

Technical disruptions may occur
Not appropriate for medical emergencies
Physical examination is limited
Certain conditions may require in-person care
Delays in evaluation or treatment due to technical issues
Security risks inherent in electronic communications
May not be covered by insurance

6. MEDICAL EMERGENCIES

I understand that telehealth services are NOT for medical emergencies. In case of emergency, I should:

Call 911 immediately
Go to the nearest emergency room
Not wait for a telehealth appointment

7. PRIVACY AND SECURITY

AllrangeKit™ uses encrypted, HIPAA-compliant technology
I am responsible for ensuring privacy on my end
I should not record sessions without permission
Technical safeguards are in place but no system is 100% secure

8. PROVIDER CREDENTIALS

All providers are licensed in accordance with state requirements
Provider credentials are available upon request
Providers may be located in different states
Interstate licensure compacts may apply

9. PRESCRIPTIONS

If medications are prescribed:

Prescriptions will be sent to my designated pharmacy
I must provide accurate pharmacy information
Controlled substances have special restrictions
Some medications cannot be prescribed via telehealth

10. INFORMED CONSENT

By accepting this consent, I acknowledge that:

I have read and understood this information
I have had my questions answered
I consent to receive telehealth services
I understand I can withdraw consent at any time
Withdrawal of consent may limit service availability

11. BILLING AND INSURANCE

Telehealth services may or may not be covered by insurance
I am responsible for any applicable fees
Billing practices are outlined in the Specific Terms Relating to Lab Services and Products

12. RIGHTS AND RESPONSIBILITIES

My Rights:

To receive quality care via telehealth
To have my privacy protected
To request in-person care when appropriate
To access my health records
To file complaints about care received

My Responsibilities:

To provide accurate health information
To participate actively in my care
To ensure a private environment
To follow treatment recommendations or inform provider if I cannot
To update contact and pharmacy information

13. CONTINUITY OF CARE

I understand that:

Telehealth may be part of ongoing care
Records will be maintained per regulatory requirements
I should inform my primary care provider of services received
Referrals may be made when appropriate

14. STATE-SPECIFIC REQUIREMENTS

Telehealth services are subject to state laws and regulations. Additional consents or limitations may apply based on my state of residence.

COMBINED ACKNOWLEDGMENT AND SIGNATURE

By clicking "I Accept", I acknowledge that:

I have read and understood both the HIPAA Authorization and Telehealth Consent
I voluntarily agree to the use and disclosure of my health information as described
I consent to receive telehealth services under the terms outlined
I understand my rights and responsibilities
I have had the opportunity to ask questions
I am at least 18 years of age
I am the person whose health information will be used and disclosed

QUESTIONS OR CONCERNS

If you have questions about this authorization or our privacy practices:

📧 Email: support@allrangekit.com

📞 Phone: +1 (608) 879-8173

🕒 Hours: Monday-Friday, 9 AM - 5 PM PST

📍 Mail: OPEN Healthcare, 1487 W 178th St., Gardena, CA 90248

ATTN: AllrangeKit™ Privacy Practice

To file a complaint:

Contact us
File with the U.S. Department of Health and Human Services
Contact your state health department

This document is available in other languages upon request.

SECTION 1: HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

1. AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION

2. INFORMATION TO BE USED AND DISCLOSED

The health information that may be used and disclosed includes, but is not limited to:

Demographic information (name, date of birth, contact information)
Health history and questionnaire responses
Laboratory test orders and requisitions
Test results and reports for any tests including but not limited to:

Sexually Transmitted Infection (STI) testing
Human Papillomavirus (HPV) testing
Gastrointestinal (GI) tract testing
Urinary Tract Infection (UTI) testing
Any other wellness or diagnostic tests offered through AllrangeKit™

Biological samples and specimen information
Communications with healthcare providers
Billing and payment information related to health services
Clinical notes and interpretations
Treatment recommendations and referrals

3. PARTIES AUTHORIZED TO USE AND DISCLOSE INFORMATION

I understand that my health information may be used and disclosed by:

AllrangeKit™ and its employees
Independent healthcare providers reviewing and authorizing tests
CLIA-certified laboratories performing test analysis
Healthcare providers delivering telehealth services
Third-party service providers supporting our operations
Pharmacy partners (if medications are prescribed)

4. PARTIES WHO MAY RECEIVE INFORMATION

My health information may be disclosed to:

Me or my authorized representatives
Healthcare providers involved in my care (at my request)
Laboratories performing testing services
Healthcare providers I designate to receive my results
Public health authorities as required by law
Other parties as required by law or court order

5. PURPOSE OF USE AND DISCLOSURE

My health information will be used and disclosed for:

Processing and authorizing laboratory test orders
Performing laboratory analysis
Delivering test results
Providing clinical consultations and telehealth services
Treatment recommendations and care coordination
Billing and payment processing
Quality improvement and patient safety activities
Communicating with me about my health and services
Complying with legal and regulatory requirements
Research purposes (only in de-identified form)

6. EXPIRATION

This authorization will remain in effect:

For as long as I maintain an active account with AllrangeKit™
Until I revoke it in writing
For records retention periods required by law

7. RIGHT TO REVOKE

I understand that I have the right to revoke this authorization at any time by submitting a written request to:

📧 Email: support@allrangekit.com

📍 Mail: OPEN Healthcare, 1487 W 178th St., Gardena, CA 90248

ATTN: AllrangeKit™ Privacy Practice

I understand that revocation will not affect actions taken before receipt of my revocation and that I may not be able to receive certain services if I revoke this authorization.

8. RE-DISCLOSURE RISKS

I understand that once my health information is disclosed pursuant to this authorization, it may no longer be protected by federal privacy laws and could be re-disclosed by the recipient.

9. REFUSAL TO SIGN

10. COPY OF AUTHORIZATION

I am entitled to receive a copy of this authorization.

SECTION 2: TELEHEALTH SERVICES CONSENT

1. NATURE OF TELEHEALTH SERVICES

I understand that telehealth involves the use of electronic communications to enable healthcare providers to provide clinical services remotely. This may include:

Video consultations
Phone consultations
Secure messaging
Asynchronous communications
Review and interpretation of test results
Treatment recommendations
Prescription services when appropriate

2. TELEHEALTH SERVICES OFFERED

AllrangeKit™ may provide telehealth services related to:

Pre-test consultations and test authorization
Review of health questionnaires
Test result delivery and interpretation
Abnormal result consultations
Treatment recommendations
Prescription of medications when clinically appropriate
Referrals to in-person care when necessary
Follow-up care related to test results

3. TECHNOLOGY REQUIREMENTS

I understand that I will need:

A device with internet connectivity
A working camera and microphone (for video visits)
A private location for consultations
Updated web browser or mobile application

4. POTENTIAL BENEFITS

Improved access to healthcare services
Convenience and reduced travel time
Timely access to test results and consultations
Continuity of care
Access to specialists not available locally

5. POTENTIAL RISKS AND LIMITATIONS

I understand that telehealth has limitations including:

Technical disruptions may occur
Not appropriate for medical emergencies
Physical examination is limited
Certain conditions may require in-person care
Delays in evaluation or treatment due to technical issues
Security risks inherent in electronic communications
May not be covered by insurance

6. MEDICAL EMERGENCIES

I understand that telehealth services are NOT for medical emergencies. In case of emergency, I should:

Call 911 immediately
Go to the nearest emergency room
Not wait for a telehealth appointment

7. PRIVACY AND SECURITY

AllrangeKit™ uses encrypted, HIPAA-compliant technology
I am responsible for ensuring privacy on my end
I should not record sessions without permission
Technical safeguards are in place but no system is 100% secure

8. PROVIDER CREDENTIALS

All providers are licensed in accordance with state requirements
Provider credentials are available upon request
Providers may be located in different states
Interstate licensure compacts may apply

9. PRESCRIPTIONS

If medications are prescribed:

Prescriptions will be sent to my designated pharmacy
I must provide accurate pharmacy information
Controlled substances have special restrictions
Some medications cannot be prescribed via telehealth

10. INFORMED CONSENT

By accepting this consent, I acknowledge that:

I have read and understood this information
I have had my questions answered
I consent to receive telehealth services
I understand I can withdraw consent at any time
Withdrawal of consent may limit service availability

11. BILLING AND INSURANCE

Telehealth services may or may not be covered by insurance
I am responsible for any applicable fees
Billing practices are outlined in the Specific Terms Relating to Lab Services and Products

12. RIGHTS AND RESPONSIBILITIES

My Rights:

To receive quality care via telehealth
To have my privacy protected
To request in-person care when appropriate
To access my health records
To file complaints about care received

My Responsibilities:

To provide accurate health information
To participate actively in my care
To ensure a private environment
To follow treatment recommendations or inform provider if I cannot
To update contact and pharmacy information

13. CONTINUITY OF CARE

I understand that:

Telehealth may be part of ongoing care
Records will be maintained per regulatory requirements
I should inform my primary care provider of services received
Referrals may be made when appropriate

14. STATE-SPECIFIC REQUIREMENTS

Telehealth services are subject to state laws and regulations. Additional consents or limitations may apply based on my state of residence.

COMBINED ACKNOWLEDGMENT AND SIGNATURE

By clicking "I Accept", I acknowledge that:

I have read and understood both the HIPAA Authorization and Telehealth Consent
I voluntarily agree to the use and disclosure of my health information as described
I consent to receive telehealth services under the terms outlined
I understand my rights and responsibilities
I have had the opportunity to ask questions
I am at least 18 years of age
I am the person whose health information will be used and disclosed

QUESTIONS OR CONCERNS

If you have questions about this authorization or our privacy practices:

📧 Email: support@allrangekit.com

📞 Phone: +1 (608) 879-8173

🕒 Hours: Monday-Friday, 9 AM - 5 PM PST

📍 Mail: OPEN Healthcare, 1487 W 178th St., Gardena, CA 90248

ATTN: AllrangeKit™ Privacy Practice

To file a complaint:

Contact us
File with the U.S. Department of Health and Human Services
Contact your state health department

This document is available in other languages upon request.