Free Colon Cancer Screening

Patient Information

Patient Name*

First Last

Date Of Birth*

Gender*

Patient Phone*

Email*

Please ensure that this address is accurate. Confirmation and Reports will only be emailed to this email address. If you enter an incorrect email, you will not receive your results.

Primary Physician

Would you like your results faxed to your primary physician?

Yes
No

You will always receive a copy of your results via email. Results will be sent to the fax number provided below. ColonoscopyAssist does not verify whether the number is accurate.

Physician Name

First Last

If you have only a practice name, enter it as first name

Physician Phone

Physician Fax

Physician Address

Street Address Address Line 2 City State Zip Code

Referral Code

Do you have a Referal Code?*

Yes
No

Referral Code*

If you were given a referral code at a recent event sponsored by ColonoscopyAssist, please enter it here.

Payment

Fecal Immunochemical Test Kit (FIT)

Price: $40.00

Donation

Total Amount

$0.00

This is the total amount being charged to your card.

Billing Address

Street Address Address Line 2 City State Zip Code

Shipping Address*

Same as Billing Address

Street Address Address Line 2 City State Zip Code

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Terms and Conditions
By signing below, you agree to the terms and conditions set forth below. If you are not the patient, you directly and expressly warrant that you have been given and have received and accepted authority to sign and execute this document on behalf of the Patient for whom it is indicated he/she has signed, and further have been expressly given and received and accepted authority to enter into a binding agreement on behalf of Patient with respect to the matters concerned herein and as stated herein.
A copy of our terms and conditions can also be found at http://colonoscopyassist.com/Terms.html

I. COMMUNICATION VIA EMAIL
1. RISK OF USING E-MAIL
Provider offers patients the opportunity to communicate by e-mail.
Transmitting patient information by e-mail, however, has a number of risks that patients should consider before using e-mail.
These include, but are not limited to, the following risks:
a. E-mail can be circulated, forwarded, and stored in numerous paper an electronic files.
b. E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients.
c. E-mail senders can easily misaddress an email.
d. E-mail is easier to falsify than handwritten or signed
documents.
e. Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
f. Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
g. E-mail can be intercepted, altered, forwarded, or used
without authorization or detection.
h. E-mail can be used to introduce viruses into computer
systems.
i. E-mail can be used as evidence in court. 
2. CONDITIONS FOR THE USE OF E-MAIL
Provider will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, Provider cannot guarantee the security and confidentiality of e-mail communication, and will
not be liable for improper disclosure of confidential information. Thus, the patients must consent to the use of e-mail for patient information.
Consent to the use of e-mail includes agreement with the following conditions:
a. All e-mails to or from the patient concerning diagnosis or treatment will be printed out and made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those e-mails.
b. Provider may forward e-mails internally to Provider’s staff and agent necessary for diagnosis, treatment,
reimbursement, and other handling. Provider will not,
however, forward emails to independent third parties
without the patient’s prior written consent, except as
authorized or required by law.
c. Although Provider will endeavor to read and respond
promptly to an e-mail from the patient, Provider cannot
guarantee that any particular e-mail will be read and
responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time sensitive matters.
d. If the patient’s e-mail requires or invites a response from Provider, and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond.
e. The patient should not use e-mail for communication
regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
f. The patient is responsible for informing Provider of any types of information the patient does not want to be sent by e-mail, in addition to those set out in 2(e) above.
g. The patient is responsible for protecting his/her password or other means of access to e-mail. Provider is not liable for breaches of confidentiality caused by the patient or any third party.
h. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.
3. INSTRUCTIONS
To communicate by e-mail, the patient shall:
a. Limit or avoid use of his/her employer’s computer.
b. Inform Provider of changes in his/her email address.
c. Put the patient’s name in the body of the e-mail.
d. Include the category of the communication in the e-mail’s subject line, for routing purposes (e.g., billing question).
e. Review the e-mail to make sure it is clear and that all
relevant information if provided before sending to Provider.
f. All emails sent by Provider to patient are considered received and read. Provider will not wait for acknowledgement from patient.
g. Take precautions to preserve the confidentiality of e-mail, such as using screen savers and safeguarding his/her computer password.
h. Withdraw consent only by e-mail or written communication to Provider.
4. PATIENT ACKNOWLEDGEMENT AND AGREEMENT
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between Provider and me, and consent to the conditions herein. In addition, I agree to the instructions outlined herein, as
well as any other instructions that Provider may impose to communicate with patients by e-mail. Any questions I may have had were answered. 
II. Liability for our Services
WHEN PERMITTED BY LAW, COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors WILL NOT BE RESPONSIBLE FOR DAMAGES, LOST PROFITS, REVENUES, OR DATA, FINANCIAL LOSSES OR INDIRECT, SPECIAL, CONSEQUENTIAL, EXEMPLARY, OR PUNITIVE DAMAGES.
TO THE EXTENT PERMITTED BY LAW, THE TOTAL LIABILITY OF  COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors, FOR ANY CLAIMS UNDER THESE TERMS, INCLUDING FOR ANY IMPLIED WARRANTIES, IS LIMITED TO THE AMOUNT YOU PAID US TO USE THE SERVICES (OR, IF WE CHOOSE, TO SUPPLYING YOU THE SERVICES AGAIN).
IN ALL CASES,  COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors, WILL NOT BE LIABLE FOR ANY LOSS OR DAMAGE THAT IS NOT REASONABLY FORESEEABLE.
III. INDEMNITY
You agree to indemnify and hold COLONOSCOPY ASSIST LIMITED and its subsidiaries, providers, affiliates, officers, agents, employees, partners and licencors harmless from any claim or demand, including reasonable attorneys' fees, made by you or any third party due to your use of COLONOSCOPY ASSIST LIMITEDs services, your violation of the TOS, or your violation of any rights of another.
IV. About these Terms
We may modify these terms or any additional terms that apply to a Service to, for example, reflect changes to the law or changes to our Services. You should look at the terms regularly. We’ll post notice of modifications to these terms on this page. We’ll post notice of modified additional terms in the applicable Service. Changes will not apply retroactively and will become effective no sooner than fourteen days after they are posted. However, changes addressing new functions for a Service or changes made for legal reasons will be effective immediately. If you do not agree to the modified terms for a Service, you should discontinue your use of that Service and inform Colonoscopy Assist via a written letter immediately. Please follow up with us to ensure that we have received the letter.
If there is a conflict between these terms and the additional terms, the additional terms will control for that conflict.
These terms control the relationship between ColonsocoscopyAssist Limited and you. They do not create any third party beneficiary rights.
If you do not comply with these terms, and we don’t take action right away, this doesn’t mean that we are giving up any rights that we may have (such as taking action in the future).
If it turns out that a particular term is not enforceable, this will not affect any other terms.
V. PRIVACY POLICY
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Who We Are
This Notice describes the privacy practices of ColonoscopyAssist™.
We will share your health information among ourselves to facilitate your treatment, payment, and health care operations.
II. Our Privacy Obligations
The law requires us to maintain the privacy of certain health information called "Protected Health Information" ("PHI"). Protected Health Information is the information that you provide us or that we create or receive about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your Protected Health Information, we are required to follow the terms of this Notice or other notice in effect at the time we use or share the PHI. Finally, the law provides you with certain rights described in this Notice.
III. Ways We Can Use and Share Your PHI Without Your Written Permission (Authorization)
In many situations, we can use and share your PHI for activities that are common in many hospitals and clinics. In certain other situations, which we will describe in Section IV below, we must have your written permission (authorization) to use and/or share your PHI. We do not need any type of permission from you for the following uses and disclosures:
A. Uses and Disclosures for Treatment, Payment and Health Care Operations. We may use and share your PHI to provide "Treatment," obtain "Payment" for your Treatment, and perform our "Health Care Operations." These three terms are defined as:
Treatment. We use and share your PHI to provide care and other services to you—for example, to diagnose and treat your illness. In addition, we may contact you to provide appointment reminders or information about treatment options. We may tell you about other health-related benefits and services that might interest you. We may also share PHI with other doctors, nurses, and others involved in your care.
Payment. We may use and share your PHI to receive payment for services that we provide to you. For example, we may share your PHI to request payment and receive payment from Medicare, Medicaid, your health insurer, HMO, or other company or program that arranges or pays the cost of some or all of your health care ("Your Payor") and to confirm that Your Payor will pay for health care. As another example, we may share your PHI with the person who you told us is primarily responsible for paying for your Treatment, such as your spouse or parent.
Health Care Operations. We may use and share your PHI for our health care operations, which include management, planning, and activities that improve the quality and lower the cost of the care that we deliver. For example, we may use PHI to review the quality and skill of our physicians, nurses, and other health care providers. As another example, we may share PHI with a Patient Relations Coordinator to resolve any complaints you may have and make sure that you have a comfortable experience with us.
In addition, we may share PHI with certain others who help us with our activities, including those we hire to perform services.
B. Your Other Health Care Providers. We may also share PHI with your doctor and other health care providers when they need it to provide Treatment to you, to obtain Payment for the care they give to you, to perform certain Health Care Operations, such as reviewing the quality and skill of health care professionals, or to review their actions in following the law.
C. Judicial and Administrative Proceedings. We may share your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
D. Law Enforcement Purposes. We may share your PHI with the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a subpoena.
E. Decedents. We may share PHI with a coroner or medical examiner as authorized by law.
F. As required by law. We may use and share your PHI when required to do so by any other law not already referred to above.
IV. Uses and Disclosures Requiring Your Written Permission (Authorization)
A. Use or Disclosure with Your Permission (Authorization). For any purpose other than the ones described above in Section III, we may only use or share your PHI when you grant us your written permission (authorization).
B. Marketing. We must also obtain your written permission (authorization) prior to using your PHI to send you any marketing materials. However, we may communicate with you about products or services related to your Treatment, case management, or care coordination, or alternative treatments, therapies, health care providers, or care settings without your permission.
C. Uses and Disclosures of Your Highly Confidential Information. Federal and state law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including any portion of your PHI that is: (1) kept in 
psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, Treatment and referral; (4) about HIV/AIDS testing, diagnosis or Treatment; (5) about venereal disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic abuse of an adult with a disability; (9) about sexual assault; or (10) Invitro Fertilization (IVF). Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact our office. You may also file written complaints with the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services. When you ask, we will provide you with the correct address for the OCR. We will not and can not take any action against you if you file a complaint with us or with the OCR.
B. Right to Receive Confidential Communications. You may ask us to send papers that contain your PHI to a different location than the address that you gave us, or in a special way. You will need to ask us in writing. We will try to grant your request if we feel it is reasonable. For example, you may ask us to send a copy of your medical records to a different address than your home address.
C. Right to Revoke Your Written Permission (Authorization). You may change your mind about your authorization or any written permission regarding your Highly Confidential Information by giving or sending a written "revocation statement" to our office. The revocation will not apply to the extent that we have already taken action where we relied on your permission.
D. Right to Inspect and Copy Your Health Information. You may request access to your medical record file, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. You can review these records and/or ask for copies. Under limited circumstances, we may deny you access to a portion of your records.
E. Right to Amend Your Records. You have the right to request that we amend PHI maintained in medical record files, billing records, and other records used to make decisions about your Treatment and payment for your Treatment.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective as of 
September, 2010.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice on this internet site page. You also may obtain any new notice by contacting us.

Signature*

Your Name*

FOBT Test Kit – Order Form

Patient Information

Primary Physician

Referral Code

Payment