HIPAA Authorization – Use and Disclosure of Protected Health Information
Effective October 23, 2018
By indicating my consent below, I authorize Baebies, Inc. to use and disclose protected health information about my baby or child, including information related to the results of the genetic testing, biochemical testing, and infectious disease testing that Baebies, Inc. performs on my baby’s specimens to: conduct research analytics to produce aggregate data about certain predictors or conditions in newborns; provide de-identified or anonymized information that does not identify my child individually to supporting partners and collaborators; create research publications and informational and promotional materials; and for internal training purposes. My child’s name will not be disclosed to third parties and my child’s name nor other information that uniquely identifies my child as an individual will be used in or linked to the results of any research analysis or included in any scientific publications using the analysis.
I also understand and agree to the following:
I will receive a copy of this authorization form or can print a copy of this page for my records.
I may refuse to provide this authorization and Baebies, Inc. will not condition services to me based on my providing this authorization.
Any information used or disclosed because I have agreed to this authorization may no longer be protected by privacy laws and may be subject to re-disclosure by the person or organization receiving it.
I have the right to revoke this authorization at any time by doing so in writing to Baebies, Inc. at PO Box 14403 Durham, NC 27709
Any revocation of this authorization by me will not apply to actions that Baebies, Inc. has already taken regarding the sharing of my child’s protected health information during the period of time that my authorization was effective.
I understand that as a result of its disclosure of my protected health information as described in this authorization, Baebies, Inc. may receive remuneration from the development or sale of products or Services.
I also understand that this authorization expires two years from the date it is completed unless otherwise revoked.
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