Consent for Service
Last Updated: Feb 28, 2022
By creating an account on Tiero to receive COVID-19 tests on a monthly basis through this website at no cost to me, I consent to the following:
1. I consent to the use of my Protected Health Information (“PHI”) by Tiero LLC, for the purpose of submitting claims to my health insurance provider and such other purposes that are permitted under the federal Health Insurance Portability and Accountability Act (HIPAA) for reimbursement of COVID-19 tests ordered through this website.
2. I consent to Tiero submitting claims to my health insurance provider on a monthly basis until such time as I notify Tiero that I no longer wish to receive further COVID-19 tests, and I assign my right to receive any health insurance or other benefits in connection with the COVID-19 tests ordered through this website to Tiero in order to permit Tiero to submit such claims. I authorize payment directly to Tiero for such claims.
3. I consent to Tiero and/or my health insurance provider contacting me in connection with the COVID-19 tests ordered through this website, including via email, phone, or text message.
5. I agree that all of the above consents apply to any other persons covered by my health insurance policy on whose behalf I order COVID-19 tests through this website, including any minors, and I affirm that I have the authority to order COVID-19 tests on such persons’ behalf, including any minors.
6. I agree that, by ordering COVID-19 tests through this website or taking such tests, I am not entering into a doctor-patient relationship with Tiero or any entity or person affiliated with Tiero, and that any questions I may have concerning such tests, including but not limited to the results of such tests and any treatment, follow up, or other issues relating to such tests, are solely my responsibility. I also agree that I will report the result of each test ordered on the website, www.Tiero.com.
8. I understand that the exact test that will be shipped by Tiero is based on availability. The COVID -19 test kits have been authorized by the FDA under an emergency use authorization.
9. I understand that while I may cancel at any time, only future orders of test kits may be canceled. I agree that any test kit that has already been ordered and has had a claim submitted to my insurance company may not be canceled.
10. Tiero’s terms and conditions may be changed at any time.