Document 6431540

Vegas STD Testing (VST)
Request and Authorization to Share Protected Health Information (PHI) Via Email Between
Provider and Clients (Adults Only)
Client N a m e : - - - - - - - - - - - - - - - SSN:
-----------------------
Phone: ___________________________
008:
----------------
Email: -------------------
Address: _____________________________________________________
I request and give my permission for the following provider to communicate with me via email
about issues concerning my care, testing, treatment, and services. I wish to limit this information
to the following information:
Vegas STD Testing
500 East Windmill Lane, Suite 115
Las Vegas, NV 89123
(702) 870-1911
[email protected]
I understand that:
a. Authorizing this form of communication is at my request. I understand emails may
not have been read within any consistent timeframe and that if I need to contact the
clinician urgently, I have been advised to call the clinic directly.
b. Emails sent to and from person email accounts are not secured data transmissions
for PHI, as defined by the Healthcare Portability and Accountability Act (HIPAA). VST
cannot guarantee internet security; for example, VST cannot assure me that emails
sent back and forth between me and my provider will not be intercepted or read
without my knowledge or permission.
c. It is my responsibility to reduce exposure of messages in my personal email account
on my laptop or desktop computer; for example, by signing-off when I leave the
computer station at the library.
d. All email communication between me and my provider regarding "care, testing,
treatment and services" will be copied and included in my medical record or chart.
e. I may cancel this request/authorization at any time by notifying my provider. I also
understand that when I give or cancel my consent, it is effective from that date
forward, and not retroactively.
f. I have a right to receive a copy of this request form.
Client Signature: _____________
Date: ___________
AUTHORIZATION TO RELEASE TEST RESULTS (HIV+G/C+RPR)
THIS IS A LEGAL BINDING AGREEMENT- READ CAREFULLY AND COMPLETE FULLY
Under State and Federal Law, you are entitled to complete anonymity and confidentiality in the testing
for HIV and/or AIDS, Gonorrhea, Chlamydia (G/C) and Syphilis (RPR). This means that you may take an
HIV/AIDS, G/C and RPR test without providing identification, you may require results to be kept
confidential, and without specific instructions from you to the contrary, require that the results be
released to no one but you.
As a performer employed in the production of sexually explicit entertainment, it is critical for you safety
and the safety of others with whom you perform that you undergo testing for HIV and /or AIDS,
Gonorrhea, Chlamydia (G/CL and Syphilis (RPR) on a regular basis and that under certain circumstances,
the testing results be disclosed to a limited number of individuals other than you.
Accordingly, you are being offered the opportunity to obtain HIV/AIDS, G/C and RPR testing at a
discounted rate and in a convenient manner through the Adult Production Health and Safety Services
(APHSS) program and the physicians providing the services. In exchange for such savings, convenience,
the receipt and sufficiency of which you hereby acknowledge as adequate consideration to support this
agreement you hereby authorize Vegas STD Testing to release the results of your Gonorrhea, Chlamydia
and Syphilis, and Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome (HIV/AIDS)
test(s) to any duly authorized agent of APHSS or others as APHSS may deem appropriate as to the safety
ofthe community, and, if desired, your Agent(s) of Record as listed below.
Initial.
You further authorize Vegas STD Testing, APHSS, and your Agent(s) of Record to disclose a positive test
results to any individual and/or entity that might have been placed at risk, or may subsequently be
placed at risk by you, in the event that you are positive. Nevada Law requires that positive Chlamydia,
Gonorrhea, HIV, and/or Syphilis results be reported by name to the local health department. The health
department keeps all information confidential. _ _ _ Initial.
You hereby indemnify and hold Vegas STD Testing, APHSS, and your Agent(s) of Record harmless for any
claims, actions, causes of actions, demands, rights, damages, costs, loss of services, expense and
compensation, of any nature whatsoever, which you now have or which may hereafter accrue on
account of, or in any way related to any known and unknown, foreseen and unforeseen, emotional,
bodily, and personal injuries resulting directly or indirectly from such testing and/or disclosure.
TERM: This authorization/agreement shall become effective immediately and shall remain in effect for
one year from the date of signature.
REDISCLOSURE: I understand that once Vegas STD Testing discloses my health information to the
recipients identified above ("any duly authorized agents of APHSS or others as APHSS may deem
appropriate as to the safety ofthe community, and your Agent(s) of Record" and "any individual and/or
entity that might have been placed at risk, or may subsequently be placed at risk by you") that APHSS
cannot guarantee that the recipient(s) will notre-disclose my health information to a third party. The
third party may not be required to abide by this Authorization or applicable federal (HIPAA) and state
law governing the use and disclosure of my health information.
REVOCATION: I understand that the authorization/agreement will remain in effect until the term if this
authorization/agreement expires or I prove written notice or revocation to Vegas STD Testing. The
revocation will be effective immediately upon Vegas STD Testing/ APHSS in reliance on this
authorization/agreement before it received my written notice of revocation. This authorization may not
be revoked by verbal request.
QUESTIONS: I may contact APHSS for answers to my questions about the privacy of my health
information at my health care provider's regular office telephone number. I understand that I have the
right to receive a copy of this authorization from my health care provider.
PHOTOCOPY: A photocopy, fax or electronic copy of this authorization/agreement shall be considered as
effective and as valid as the original.
Full Legal Name (please print clearly)
Agent(s) of Record (if applicable)
Signature
Date
Email
Phone
I do NOT authorize to release the results of my Gonorrhea, Chlamydia and Syphilis, and Human
Immunodeficiency Virus or Acquired Immune Deficiency Syndrome (HIV/AIDS) test(s) to any duly
authorized agent of APHSS or others as APHSS may deem appropriate as to the safety of the community,
and, if applicable, my Agent(s) of Record as listed above.
Signature
Date
By adding APHSS to the HIPAA agreement you will be listed as "available" to producers who wish to check to see if you
are available on the APHSS database. APHSS is free to performers and completely voluntary. You can ask to be removed
from the APHSS system at any time by calling FSC at 818-348-9373.
PLEASE PRINT CLEARLY
Legal Name: _ _ _ _ _ _ _ _ _ _ _ _ _ __
Phone Number: _ _ _ _ _ _ _ _ _ _ _ _ __
Email Address: _ _ _ _ _ _ _ _ _ _ _ _ __
Signature: _________________________________
{Signing this document gives permission for the clinic/lab to enter the date and only the date of your test in the APHSS
availability dashboard. For security reasons, no medical or personal information, other than the information listed
above, will be kept in the database)
We will email you with your account information.
Show me the money .... Performer Subsidy Fund
Manwin has agreed to donate $10,000 monthly to be divided up amongst performers who have tested to subsidize
performer testing. That means that each performer participating in APHSS will receive a check in the first half of the
month to partially subsidize what he/she spent on testing in the previous month. If you want to receive a subsidy check,
please write your address below. {NOTE to protect performer privacy, this information will be kept completely separate
from the APHSS database in an accounting database on a completely different server.)
PLEASE Print Clearly
Address
-----------------------------------------------------------------
City_ _ _ _ _ _ _ _ _ _ __
State--------
ZIP _ _ _ __
Vegas STD Testing
Medical Screening Form
Please print clearly.
Full Legal Name
Date of Birth
Circle YES or NO
Have you or any immediate family member had:
Cancer?
Yes
No
Circle YES or NO
Do you have a history of:
Allergies/ Asthma?
Headaches?
Bronchitis?
Kidney Disease?
Rheumatic Fever?
Ulcers?
Sexually Transmitted Disease?
Seizures?
If yes, s p e c i f y : - - - - - - - - - - - - D~b~e~
Yes
No
High Blood Pressure?
Yes
No
Heart Disease?
Yes
No
Yes
No
Angina/Chest Pain?
No
Stroke?
Yes
Circle YES or NO
In the past 3 months, have you had or do you
experience:
A change in your health?
Yes
Nausea/Vomiting?
Yes
Yes
Fever/Chills/Sweats?
Unexplained weight change?
Yes
Numbness or tingling?
Yes
Changes in appetite?
Yes
Difficulty swallowing?
Yes
Changes in bowl or bladder
Yes
function?
Shortness of breath?
Yes
Dizziness?
Yes
Upper Respiratory Infection?
Yes
Urinary Tract Infection?
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Do you or have you in the past smoked tobacco?
0 Yes 0 No
If yes, number of packs ____# Years _ _ __
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Do you drink alcoholic beverages?
0 Yes 0 No
If yes, how many drinks do you routinely have per
week? _________________
Any drug use in the past?
0 Yes 0 No
If yes, please s p e c i f y : - - - - - - - - - - Last drug u s e : - - - - - - - - - - - - - Are you new to the adult productions industry or
has it been more than six (6) months since your last
performance?
D New/Within 6 mo. D After 6 mo.
Please provide the following information regarding
your Agent:
Agent Name: __________________
Company: _ _ _ _ _ _ _ _ _ _ _ _ _ ____
Phone Number(s): - - - - - - - - - - - -
Last tobacco u s e - - - - - - - - - - - List medications currently using:
Allergies to medication(s)?
0 Yes
0 No
If yes, please list:
Date of last physical examination:
Last Physician Name, Address and Phone Number:
11
Vegas STD Testing
For Female Patients:
Menstruation: Age at first period:
Regular/Irregular every _ _ _ _ Days
How many days is your flow?
Q Mild Flow Q Moderate Flow Q Heavy Flow
Date of last menstrual period (first day of period): _ _ _ _ _ Date of previous period: _ _ __
Q No
Are you currently pregnant?
Q Yes
Total number of pregnancies: _ _ __
Number of vaginal deliveries:
C-Section: _ _ _ Miscarriages: _ _ _ Abortions: _ _ __
Contraception: Are you presently using any of the following?
Q Birth Control Pills Q Diaphragm Q IUD CJ Condoms CJ Inserts CJ Depo Shots CJ Foam
Q Tubal Sterilization: Date
Q Other-----------------Venereal Disease: Where you ever treated for the following?
D Gonorrhea D Chlamydia D Syphilis D Herpes D Venereal Warts
CJ Hepatitis Q PID/Tubalovarian Abscess
Last Pap Smear: Date _ _ _ _ __
Q Normal Q Abnormal
Gynecological Problems in the past:
CJ Ovarian Cysts CJ Uterine Fibroids Q Pelvic Pain CJ Endometrioses CJ Ectopic Pregnancy
Q Infertility Q O t h e r - - - - - - - - - - - - - - - - - - - - - - - - - - - Gynecological Surgeries/Procedures: {please give dates)
D Cone Biopsy D Cryosurgery D Laser Surgery D Laparoscopy Q Other Surgery------Have you had a mammogram done? Q Yes CJ No
If yes, w h e n ? - - - - - - - - - - -
For Male Patients:
Do you have any penal discharge?
Q Yes D No
Do you have any burning or pain when urinating?
Q Yes Q No
Do you have any testicular pain?
Q Yes CJ No
Have you ever had any venereal disease(s)?
CJ Yes Q No
If yes, please check:
Q Gonorrhea CJ Chlamydia Q Syphilis Q Herpes
Q Hepatitis Q Epididymitis D Prostatitis D Venereal Warts
Do you use any performance enhancing medication {e.g. Viagra, Levitra, etc.) or herbs? Q Yes
Q No
If yes, please s p e c i f y : - - - - - - - - - - - - - - - - - - - - - - - - - - - - Do you use any blood pressure or heart-related medication {e.g. Nitroglycerin, Nitrate, etc.)?
DYes 0 No
If yes, please s p e c i f y : - - - - - - - - - - - - - - - - - - - - - - - - - - - Do you have a penile implant?
Patient Signature
21
Q
Yes
Q
No
Date