Patient Agreement v2.0
IMPORTANT: PLEASE READ THIS AGREEMENT CAREFULLY BEFORE CHECKING THE BOX, IT IS A LEGALLY BINDING AGREEMENT. BY USING THE SERVICES YOU ARE CONFIRMING THAT YOU HAVE READ THIS AGREEMENT AND THAT YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH HEREIN. IF YOU DO NOT AGREE WITH ANY OF THE TERMS OR CONDITIONS SET FORTH HEREIN, DO NOT ORDER ANY LAB TESTS.
This Patient Agreement (the “Agreement”) is made between you, the patient (“You”), and Ulta Lab Tests, LLC (“Ulta Lab Tests”). This Agreement governs Your use of Ulta Lab Tests’ services (the “Services”).
As a condition to Your use of the Services, You agree as follows:
1. Background. Provided You are at least 18 years old and in full compliance with this Agreement and other requirements of Ulta Lab Tests, Ulta Lab Tests will provide You with the Services outlined on the Ulta Lab Tests website. The Services include allowing You to purchase medical laboratory and other services via Your patient portal on the Ulta Lab Tests website (“Your Portal”). You will be able to track Your lab test results through Your Portal. You will receive a receipt for Your lab tests including the amount You paid and the CPT codes associated with Your lab tests. Ulta Lab Tests does not accept insurance or file insurance claims. For patients covered under private insurance plans or programs, You should confirm in advance whether charges may be submitted for reimbursement. CHARGES FOR LAB TESTS MAY NOT BE SUBMITTED FOR REIMBURSEMENT FROM ANY STATE, FEDERAL OR OTHER GOVERNMENTALLY FUNDED HEALTH PLAN OR PROGRAM, INCLUDING WITHOUT LIMITATION MEDICARE, MEDICAID, OR ANY SUBSIDIZED EXCHANGE POLICY. You may purchase goods and services from third parties via Your Portal. You may also utilize the Services on behalf of a minor provided that you are the legal parent or guardian of the minor.
2. Portal Access. Your Portal is intended as a secure online means for you to order services and access Your confidential medical record information. You will have a unique user name and password which You must keep confidential. You are responsible for any activity through Your Portal. If You allow others to use Your user name and password, they will be able to view Your confidential medical record information. Ulta Lab Tests, its third-party affiliates that You order tests through (“Third-Part Affiliates”), and its independent contractors have no responsibility concerning any breach of Your confidential medical record information due to access of Your Portal with Your user name and password. If You believe that the confidentiality of Your password has been compromised, You must notify Ulta Lab Tests immediately at “Contact Us” via Your Portal and You should change to a new password by following the procedure described in Your Portal.
3. No Medical Advice. Ulta Lab Tests may provide general information related to various medical conditions and their treatment. Such information is provided for informational purposes and for your general interest only. Such information is not intended to be a substitute for medical advice, diagnosis or treatment provided by a doctor or other qualified healthcare professional (a “Healthcare Professional”). Ulta Lab Tests is not a Healthcare Provider or medical testing laboratory. You should not use the information contained in the Ulta Lab Tests website for diagnosing or treating a health condition, problem or disease. Please consult with Your Healthcare Professional to see if any information presented on the Ulta Lab Tests website is appropriate for You. Ulta Lab Tests does not practice medicine or any other licensed profession, and does not interfere with the practice of medicine or any other licensed profession by Healthcare Professionals, each of whom is responsible for his/her services and compliance with the requirements applicable to his/her profession and license. DO NOT USE YOUR PORTAL IN THE CASE OF EMERGENCY – IMMEDIATELY CONTACT YOUR HEALTHCARE PROFESSIONAL OR CALL 911.
4. Your Information. You represent and warrant that the information used to register as a patient is, and will at all times be, true, accurate and complete. Ulta Lab Tests will maintain Your registration and health information, test results, records regarding Your order of Services and all other information collected by Ulta Lab Tests from You (collectively “Your Information”) in a computer database maintained by Ulta Lab Tests or third party providers such as Amazon and Authorize.Net. Ulta Lab Tests may use Your Information in accordance with this Agreement and the following terms, conditions and policies which are also available on the Ulta Lab Tests website:
Notice of Privacy Practices
Website Terms and Conditions
To the extent required by law for You to receive Your test results from the testing laboratory, You hereby: (a) request that the testing laboratory send a copy of the test results to You via Your Portal; and (b) authorize Ulta Lab Tests to convey such request to the testing laboratory.
5. Notices. You authorize Ulta Lab Tests to provide You notices of any kind, including notices of critical laboratory tests results and those required under HIPAA (defined below), to any contact destination you have given Ulta Lab Tests such as by email, telephone, cellular phone, text message or similar mode. This authorization includes leaving messages for You at such contact destinations. You understand that there are risks presented by using the Services including Your receipt of information about Your health (such as genetic or metabolic characteristics) that You may prefer not to know, and which may indicate conditions or problems that may be upsetting to You or even incurable, and You assume those risks.
6. Follow-up with Healthcare Professional or Public Health Agency. You represent and warrant that: (a) You will contact a Healthcare Professional and/or Public Health Agency if, and in such time and manner as, You are requested to do so by Ulta Lab Tests; (b) You will never delay seeking advice from Your primary care physician or other Healthcare Professional due to information provided through Ulta Lab Tests; and (c) You will seek emergency help when needed, within the recommended time frame, and continue to consult with Your primary care physician as recommended by him/her or other Healthcare Professional.
7. HIPAA and Consent. You acknowledge that Ulta Lab Tests may not be a “covered entity” as defined in the Health Insurance Portability and Accountability Act and the regulations promulgated under that Act (“HIPAA”). Your Healthcare Professionals and the third party independent medical testing laboratories utilized through Ulta Lab Tests are likely “covered entities” and therefore subject to HIPAA. You must provide appropriate HIPAA authorizations before accessing the Services. Additionally, You hereby give the authorizations contained in Exhibit A attached to this Agreement. Further, You consent to the procedures involved in collecting the specimen (including any blood draw), processing the test, and reporting the test results. You understand that the test results are for screening purposes only and are not a diagnosis, and that tests can give false positive or false negative results for a variety of reasons. You hereby release and discharge Ulta Lab Tests and other organizations associated with this testing, and all of their parent and affiliate companies, officers, directors, managers, employees, agents, contractors, representatives, successors and assignees, from any and all liability, claims, damages, losses and costs of any kind, directly or indirectly arising from or in any way connected with, or the reporting or dissemination of information derived from, the specimen collection/blood draw and test(s) indicated above (including the failure of a test to detect any particular health problem).
8. No Warranties. THE ULTA LAB TESTS WEBSITE (INCLUDING ANY ULTA LAB TESTS CO-BRANDED WEBSITE), YOUR PATIENT PORTAL AND THE SERVICES ARE ALL PROVIDED WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, ACCURACY, NON-INFRINGEMENT, FREEEDOM FROM COMPUTER VIRUS, AND WARRANTIES ARISING FROM COURSE OF DEALING OR COURSE OF PERFORMANCE. NEITHER ULTA LAB TESTS NOR ANY THIRD PARTY AFFILIATE MAKE ANY WARRANTY OR REPRESENTATION OF ANY KIND REGARDING THE USE OF THE WEBSITE, YOUR PORTAL OR THE SERVICES, OR AS TO THEIR ACCURACY, CURRENCY, RELIABILITY OR COMPLETENESS; AND ALL SUCH MATTERS ARE SUPPLIED “AS-IS”.
9. Limitation of Liability. UNDER NO CIRCUMSTANCES WILL ULTA LAB TESTS OR ITS THIRD-PARTY AFFILIATES BE LIABLE FOR ANY CONSEQUENTIAL, INDIRECT, INCIDENTAL, SPECIAL, OR PUNITIVE DAMAGES OF ANY KIND. NEITHER ULTA LAB TESTS, NOR ITS THIRD-PATY AFFILIATES, INCLUDING THEIR RESPECTIVES OFFICERS, MANAGERS, EMPLOYEES OR AGENTS MAY BE DEEMED LIABLE FOR THE ACTIONS OR OMISSIONS OF ULTA LAB TESTS’ THIRD PARTY MEDICAL TESTING LABORATORIES, HEALTHCARE PROFESSIONALS AND SERVICE PROVIDERS, AND YOU HEREBY WAIVE ANY AND ALL CLAIMS AGAINST ULTA LAB TESTS AND/OR ITS THIRD-PARTY AFFILIATES ARISING FROM OR RELATING TO THE SERVICES.
10. Changes to Terms and Conditions. This Agreement constitutes the entire agreement between You and Ulta Lab Tests regarding the Services. Ulta Lab Tests may amend this Agreement at any time by providing written notice of such amendment at least fifteen (15) days prior to the effective date of such amendment. Your continued use of the Services under this Agreement following the effective date of any such amendment constitutes Your affirmative agreement to the terms of such amendment. Your sole remedy in the event that You reject an amendment is to terminate this Agreement. This Agreement will not be deemed to be changed, modified or altered by reason of any comments, suggestions, directions or guidance offered to Ulta Lab Tests.
11. Termination. Either party may terminate this Agreement at any time on written notice with or without any reason. Upon termination Your access rights to the Services shall terminate. All Sections of this Agreement which by their nature survive termination of this Agreement shall survive. Termination of this Agreement is Your sole right and remedy with respect to any dispute with Ulta Lab Tests; this includes without limitation any dispute related to, or airing out of: (a) this Agreement or Ulta Lab Tests’ enforcement or application of this Agreement; (b) any policy or practice of Ulta Lab Tests or Ulta Lab Tests’ enforcement or application of these policies; (c) Your ability to access and/or use the Services; (d) any Ulta Lab Tests software or services provided by or through Ulta Lab Tests; or (e) the amount or type of fees, applicable taxes, billing methods, or any change to the fees, applicable taxes, or billing methods.
12. Choice of Law; Venue; Waiver of Jury Trial. This Agreement shall be governed by and interpreted according to the laws of the State of Arizona without regard to its conflicts of law provisions. Any action, suit or proceeding You bring related to this Agreement or Your relationship with Ulta Lab Tests must be brought in a court of competent jurisdiction in Maricopa County, Arizona, and You waive any right to bring the action in any other venue. YOU HEREBY WAIVE ALL RIGHTS TO TRIAL BY JURY IN ANY ACTION, SUIT OR PROCEEDING BROUGHT TO RESOLVE ANY DISPUTE WITH ULTA LAB TESTS OR ITS AFFILIATES, WHETHER ARISING IN CONTRACT, TORT OR OTHERWISE, ARISING OUT OF, CONNECTED WITH, RELATED OR INCIDENTAL TO THIS AGREEMENT, THE TRANSACTIONS CONTEMPLATED HEREBY AND/OR THE RELATIONSHIPS ESTABLISHED AMONG THE PARTIES HEREUNDER.
13. Severability. If any provision of this Agreement or the application of any such provision to any party or circumstances shall be determined by any court of competent jurisdiction to be invalid and unenforceable to any extent, the remainder of this Agreement or the application of such provision to such person or circumstances other than those to which it is so determined to be invalid and unenforceable, shall not be affected thereby, and each provision hereof shall be validated and shall be enforced to the fullest extent permitted by law.
14. Binding Agreement. This Agreement is between You and Ulta Lab Tests only, and may not be deemed to create any right in any third party. This Agreement shall be binding upon each party’s respective successors, trustees, assigns and heirs. You may not assign this Agreement or any portion of it. Ulta Lab Tests may assign this Agreement with or without notice to You. The headings in this Agreement are inserted for convenience only; the provisions of this Agreement shall control.
15. Electronic Signature Binding. Clicking the acceptance button to this Agreement, or otherwise submitting Your electronic signature, shall be deemed to have the same effect as Your original signature.
(Patient Authorization for Use and Disclosure of Protected Health Information)
I authorize my health care providers, including University Services, its physicians and its staff, and the laboratories that run medical tests for me to use and/or disclose certain protected health information about me to Ulta Lab Tests, LLC (“Ulta Lab Tests”) and its affiliates for the purposes stated below.
This authorization applies to the following protected health information about me: the laboratory requisition submitted by Ulta Lab Tests and the laboratory test values which are the result of the laboratory test(s) requested in the requisition.
For avoidance of doubt, I specifically authorize the transfer of this information between and among myself and the following individuals, organizations and their representatives: i) Ulta Lab Tests; ii) University Services staff and physician of record, and iii) the reference laboratory of record.
I understand that University Services physician of record may be required to receive my lab test results before I do, and that this physician’s authorization to release those results to Ulta Lab Tests may also be required before I receive my results.
The protected health information will be used or disclosed for the sole purpose of complying the state and federal laws which may require a physician of their agent to: i) review and approve a laboratory requisitions; and ii) review the laboratory test results. This review may be conducted for any reason, including in the event laboratory values, which are outside of normal ranges, require the physician or its agent to contact me.
The purposes outlined above are provided so that I can make an informed decision whether to allow release of the information to the parties referenced in this authorization. This authorization will expire on year after the date of this authorization.
I understand that I have a right to receive a copy of this authorization. I understand that the sole purpose of the laboratory test is to generate the results of the tests that I have requested, and the laboratory tests will not be requisitioned unless I sign this authorization. I have the right to refuse to agree to this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing at any time, except that the revocation will not apply to any information already disclosed by the parties referenced in this authorization who have acted in reliance upon this authorization. My written revocation must be submitted to the privacy officers at:
University Services and Ulta Lab Tests, LLC
2837 Southampton Road 8436 E. Shea Blvd., Suite 102
Philadelphia, PA 19154 Scottsdale, AZ 85260
I have reviewed this authorization, I agree to its terms and representations, and I acknowledge that I have
the option to print a copy of it.