Authorization Form for Email Receipt of COVID-19 Test Results

To obtain your COVID-19 test results , you may choose one of the following options:

  1. Access your lab results via the patient portal (18 years old or older).
  2. Complete the form below.

If results are not needed promptly, please complete the "Authorization for Access/Release of Protected Health Information" form found on CapitalHealth.org and select "Request Your Medical Records." Please download, print, complete and return the form to the Health Information Management Department.

Patient's Address

By consenting to the use of email with Capital Health, you agree that Capital Health may send you an email containing your COVID-19 status.

Information stored by Capital Health is encrypted. When we send you an email, or you send us an email, the information that is sent or received may not be encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.

Capital Health will use reasonable means to protect the privacy of your health information. However, because of the risks outlined above, Capital Health cannot guarantee that email will be confidential. Additionally, Capital Health will not be liable in the event that you or anyone else inappropriately uses or accesses your email. Capital Health will not be liable for improper disclosure of your health information that is not caused by Capital Health intentional misconduct.

ACKNOWLEDGMENT

By completing this form, I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communications of email between Capital Health and me, and consent to the conditions outlined herein, as well as any other instructions that Capital Health may impose to communicate with me by email. Any questions I may have had were answered. I understand that this consent is valid until I revoke the consent as outlined above, except to the extent that a person who is to make a communication has already acted in reliance upon this authorization.

Capital Health will have a limited capacity to read emails sent from patients and you should not use email to communicate with Capital Health after receiving your results. If you need to speak to your provider concerning your results, please contact your provider directly.

This authorization is contingent upon review and approval by the Health Information Management Department.

Term/Expiration

I understand that by law, I do not have to release this information and I choose to do so voluntarily. I may cancel this authorization by providing a written revocation to Capital Health, Health Information Management Department at the Regional or Hopewell address listed above. The revocation will be effective upon receipt of my written notice, except that the revocation will not have any effect on any action by Capital Health in reliance on this Authorization before it received my written notice of revocation. This authorization will automatically expire twelve (12) months from the date listed below. I understand that I may refuse to sign this form and that my health care and the payment for my health care will not be affected if I do not sign this form. I understand that once this information is disclosed, it is no longer protected by Federal