AUTHORIZATION FOR USE AND DISCLOSURE OF

PROTECTED HEALTH INFORMATION

I hereby authorize Mako Medical Laboratories, LLC ("Mako") and Central Ozarks Medical Center to use and disclose to State of Missouri, Department of Health and Senior Services ("DHSS"); Missouri Coalition for Primary Health Care dba Missouri Primary Care Association ("MPCA"); and any entity with which or MPCA may contract to communicate my test results to me ("Authorized Recipients"), the results of my COVID-19 test for such Authorized Recipient’s use related to the global COVID-19 pandemic.

I further authorize my test results to be disclosed to the county, state or to any other governmental entity as may be required by law.

I further understand that this authorization can be revoked at any time except to the extent that disclosure made in good faith has already occurred in reliance on it. I understand that I may refuse to sign this authorization and that Central Ozarks Medical Center will not perform COVID-19 testing on me. This authorization will expire within one (1) year unless specified below.

I understand that if the Authorized Recipient/s named above are not subject to the federal privacy protection regulations, my Protected Health Information may be subject to further disclosure by the Authorized Recipients and the information will no longer be protected under the federal privacy protection regulation issued by the U.S. Department of Health and Human Services.

I understand that I may inspect and copy the information to be used or disclosed, as provided in C.F.R. 164.524. I understand I have a right to a signed copy of this Authorization upon request.

To the fullest extent permitted by law, I hereby release, discharge and hold harmless the State, MPCA, Mako, Central Ozarks Medical Center, and any entity with which Central Ozarks Medical Center or MPCA may contract to communicate my test results to me and their employees, members, directors, officers, and the attending physician from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein.

The phone number I provided above is secure and I am authorizing this phone number to receive medical texts, calls and voicemails, related to my COVID test results and other medically related information. I understand that this phone number may be shared with county, state or other governmental entities as required.