HIPAA Authorization

If you agree to undergo testing, your test will be administered and collected by representatives of Crafty Chicago and/or Simple Laboratories. To allow the necessary event staff  to receive your results and related testing information, you will need to authorize provider to release your results to the event's Covid Compliance manager, the Executive in charge and necessary staff, "Authorized personnel". Your results and demographic information will be reported to the Illinois Department of Public Health and CDC as is required by local and federal compliance law. 

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By completing and submitting this HIPAA Authorization Form you are authorizing Crafty Chicago, Simple Laboratories, or it's designee to disclose your demographic information (including name, date of birth, email address, phone number, race, gender) and your results to the authorized personnel solely for the purposes described in this authorization. This authorization applies to the disclosure of your initial test to the Authorized Personnel and any additional testing you receive as part of this testing program, until the Authorization expires or it's being revoked. 

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If you refuse to sign this Authorization, you will not be able to receive the test and may not be able to participate in the production.

 

You have a right to receive a copy of this Authorization. 

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I understand for answers to questions about the privacy of my health information I may contact provider at: 847-525-6498. 

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By Clicking Below, I certify that I have read this Authorization and authorize Crafty Chicago LLC  to disclose my information to the production and health agencies as described in this Authorization.