Please fill out each question completely.
If you think you have a medical emergency, call your doctor or 911 immediately or go to the emergency room.
Do not rely on electronic communications or communications through this application for immediate or urgent medical needs.
The purpose of this self-health screening is only an informational tool and does not give medical advice, diagnosis, or treatment, this can be done only by a license healthcare professional.
Once all the questions have been completed your information will be sent to a licensed health professional to set-up an appointment with a physician via tele-health. This would require a laptop/computer with a camera or a phone with a camera. Please understand that until the physician assesses your health concerns, these are ONLY questionnaires and are not giving you any medical advice, diagnosis, or treatment.
ALL demographics and medical data is required in order for the health care professional to contact you for the tele-health appointment and assessment. Please have a government identification and insurance card present for verification purposes.
The privacy and security of Patients’ individually identifiable health information provided to Capstone in connection with Services may be protected by federal law Health Insurance Portability and Accountability Act of 1996. (HIPAA), the HITECH Act, and their regulations) and state privacy laws, because Capstone provides Services to health care providers. This health information Protected Health Information (PHI). PHI is information that includes, but is not limited to, identifying data such as name, social security number, address, contact information, as well as information about personal health issues and insurance submitted through our Services. Capstone collects PHI and other PHI that you voluntarily submit. Privacy is of the utmost importance, so we are committed to protecting and keeping confidential all PHI that identifies an individual whether or not it relates to an individual’s past, present, or future physical or mental health condition. PHI may be used and disclosed by Capstone as necessary to provide Services, for our own management and operations, to meet our legal obligations, and for any other purpose for which Patients have given consent. We may share PHI with third parties and government agencies for these purposes in compliance with applicable law.
We use your PHI for treatment, payment, or healthcare operations purposes and for other purposes permitted or required by law. We need your written authorization to use or disclose your health information for any purpose not covered by one of the categories below. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your PHI for marketing purposes or sell your PHI, unless you have signed an authorization. You may revoke any authorization you sign at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons stated in your authorization except to the extent we have already taken action based on your authorization.
Users may browse the informational areas of the Site without registering with. However, registration is required to use the Services. Once a Healthcare Provider has registered with us and subscribed to our Services, the Healthcare Provider can then invite Patients to use the Services. After receiving an invite, the Patient would then need to register for an account to use the Services. We may share your contact information with health care professionals involved in collection of any biospecimens, professional facilities or clinics, clinical laboratories that process collected biospecimens and relevant public health authorities, such as the California Department of Public Health (CDPH) and the United States Centers for Disease Control and Prevention (CDC), public health agencies and FDA, for purposes related to performing tests, administering and improving the testing program and for public health purposes.
Certain features and Services are available to patients because their Healthcare Providers use our Services. To register, Healthcare Providers must provide certain information about themselves and their practices including: the Healthcare Provider’s name, date of birth, gender, address, email, mobile and work phone; the Healthcare Provider’s practice name, address, phone number and fax number; and a user id and password. We may also collect certain optional information, including: middle name or initial, bank account or other payment information and other contact details, picture and communication preferences.
Patients must provide certain information, including: name, date of birth, gender, address, email, mobile and work phone, as well as a user id and password. We may also collect certain optional information, including: middle name or initial, home phone and other contact info, pharmacy name and contact details, other demographic information, health insurance information, credit card number and billing details, picture and communications preferences. In addition, the Patient can communicate other health-related information to the Healthcare Provider during a video consultation
Capstone Services will use and disclose your PHI for purposes of billing and payment. For example, we may disclose your PHI to health plans or other payers to determine whether you are enrolled with the payer or eligible for health benefits or to obtain payment for our services. If you are insured under another person’s health insurance policy (for example, parent, spouse, domestic partner or a former spouse), we may also send invoices to the subscriber whose policy covers your health services website or third party website not affiliated with Capstone. Capstone is not affiliated with any healthcare provider and is a third party independent clinical laboratory providing health care providers with laboratory results.
The Capstone website may use "cookies" to help you personalize your online experience. A cookie is a text file that is placed on your hard disk by a web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you and can only be read by a web server in the domain that issued the cookie to you. One of the primary purposes of cookies is to provide a convenience feature to save you time. The purpose of a cookie is to tell the Web server that you have returned to a specific page. For example, if you personalize Capstone pages, or register with Capstone site or services, a cookie helps Capstone to recall your specific information on subsequent visits. This simplifies the process of recording your personal information, such as billing addresses, shipping addresses, and so on. When you return to the same Capstone website, the information you previously provided can be retrieved, so you can easily use the Capstone features that you customized. You have the ability to accept or decline cookies. Most Web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies if you prefer. If you choose to decline cookies, you may not be able to fully experience the interactive features of the Capstone services or websites you visit. We may automatically collect the following information about your use of our Site or Services through cookies, web beacons, and other technologies: your domain name; your browser type and operating system; web pages you view; links you click; your IP address; a time and date stamp and the length of time you visit our Site and or use our Services; the referring URL, or the webpage that led you to our Site; and your browser type. We may combine this information with other information that we have collected about you, including, where applicable, your user name, name, and other personal information Sharing Information with Third Parties Capstone does not sell, rent or lease its customer lists to third parties. Capstone may share data with trusted partners to help perform statistical analysis, send you email or postal mail, provide customer support, or arrange for deliveries. All such third parties are prohibited from using your personal information except to provide these services to Capstone, and they are
required to maintain the confidentiality of your information.
Capstone may disclose your personal information, without notice, if required to do so by law or in the good faith belief that such action is necessary to: (a) conform to the edicts of the law or comply with legal process served on Capstone or the site;
(b) protect and defend the rights or property of Capstone; and/or (c) act under exigent circumstances to protect the personal safety of users of Capstone, or the public.
Capstone may keep track of the websites and pages our users visit within Capstone, in order to determine what Capstone services are the most popular. This data is used to deliver customized content and advertising within Capstone to customers whose behavior indicates that they are interested in a particular subject area.
Capstone secures your personal information from unauthorized access, use, or disclosure. Capstone uses the following methods for this purpose: SSL Protocol. When personal information (such as a credit card number) is transmitted to other websites, it is protected through the use of encryption, such as the Secure Sockets Layer (SSL) protocol.
We strive to take appropriate security measures to protect against unauthorized access to or alteration of your personal information. Unfortunately, no data transmission over the Internet or any wireless network can be guaranteed to be 100% secure. As a result, while we strive to protect your personal information, you acknowledge that: (a) there are security and privacy limitations inherent to the Internet which are beyond our control; and (b) security, integrity, and privacy of any and all information and data exchanged between you and us through this Site cannot be guaranteed.
Capstone does not knowingly collect personally identifiable information from children under the age of thirteen. If you are under the age of thirteen, you must ask your parent or guardian for permission to use this website.
From time to time, Capstone may contact you via email for the purpose of providing announcements, promotional offers, alerts, confirmations, surveys, and/or other general communication. In order to improve our Services, we may receive a notification when you open an email from Capstone or click on a link therein.
If you would like to stop receiving marketing or promotional communications via email from Capstone, you may opt out of such communications by email@example.com.
We may store your data on servers provided by third party hosting vendors with whom we have contracted.
Capstone welcomes your questions or comments regarding this Statement of Privacy. If you believe that Capstone has not adhered to this Statement, please contact Capstone at: firstname.lastname@example.org. Telephone number: 951-465-3500
Effective as of April 01, 2020
PATIENT CONSENT: I AGREE THE SPECIMEN IDENTIFIED ON THIS FORM IS MY OWN AND IT IS NOT ALTERED. I AM VOLUNTARILY SUBMITTING THIS SPECIMEN FOR THE PURPOSE TO ENHANCE PATIENT CARE, PROVIDING OBJECTIVE DOCUMENTATION OF MY TREATMENT PLAN FOR MY PHYSICIAN. I HEREBY AUTHORIZE MY PHYSICIAN TO RELEASE PERSONAL HEALTH INFORMATION TO Capstone Clinical Labs OR A CLIA-CERTIFIED LABORATORY OR THEIR DESIGNEE FOR ANY PURPOSES, CONSISTENT WITH HIPAA INCLUDING BILLING, AUDITS, AND OTHER PURPOSES.
I UNDERSTAND AND AGREE THAT:
THIS AUTHORIZATION IS VOLUNTARY. MY HEALTH INFORMATION MAY CONTAIN INFORMATION CREATED BY OTHER PERSONS OR ENTITIES INCLUDING HEALTH CARE PROVIDERS AND MAY CONTAIN MEDICAL, PHARMACY, DENTAL, VISION, MENTAL HEALTH, SUBSTANCE ABUSE, HIV/AIDS, PSYCHOTHERAPY, REPRODUCTIVE, COMMUNICABLE DISEASE AND HEALTH CARE PROGRAM INFORMATION: I MAY NOT BE DENIED TREATMENT, PAYMENT FOR HEALTH CARE SERVICES, OR ENROLLMENT OR ELIGIBILITY FOR HEALTH CARE BENEFITS IF I DO NOT SIGN THIS FORM MY HEALTH INFORMATION MAY BE SUBJECT TO RE-DISCLOSURE BY THE RECIPIENT, AND OF THE RECIPIENT IS NOT A HEALTH PLAN OR HEALTH CARE PROVIDER, THE INFORMATION MAY NO LONGER BE PROTECTED BY THE FEDERAL PRIVACY REGULATION.THIS AUTHORIZATION WILL EXPIRE ONE YEAR FROM THE DATE I SIGN THE AUTHORIZATION. I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY NOTIFYING MY INSURANCE POLICY IN WRITING; HOWEVER, THE REVOCATION WILL NOT HAVE AN EFFECT ON ANY ACTIONS TAKEN PRIOR TO THE DATE OF MY REVOCATION IS RECEIVED AND PROCESSED.
ASSIGNMENT OF BENEFITS: I HEREBY AUTHORIZED AND WANT THE PAYMENT TO GO TO CAPSTONE CLINICAL LABS TO RECEIVE PAYMENT FOR THIS BILL FROM MY INSURANCE COMPANY (THIS IS AN “ASSIGNMENT” AND "POWER OF ATTORNEY"). I WANT MY HEALTH INSURER TO PAY THE PROVIDER FOR ANY HEALTH CARE SERVICES I OR MY DEPENDENT RECEIVED THAT ARE COVERED UNDER MY HEALTH INSURANCE. WITH MY ASSIGNMENT, THE PROVIDER CANNOT SEEK PAYMENT FROM ME, EXCEPT FOR ANY CO-PAYMENT, COINSURANCE OR DEDUCTIBLE THAT WOULD BE OWED IF I OR MY DEPENDENT USED A PARTICIPATING PROVIDER. IF MY INSURER PAID ME FOR THE SERVICES, I AGREE TO SEND THE PAYMENT TO THE PROVIDER WITHIN 15 DAYS WITH A TRACKING NUMBER.
APPEAL AUTHORIZATION: I HEREBY AUTHORIZE CAPSTONE CLINICAL LABS, INC AND THEIR DESIGNEE TO ACT AS MY FINANCIAL REPRESENTATIVE IN REQUESTING: A COMPLAINT, AN APPEAL, AND DOCUMENTS FROM MY INSURANCE PROVIDER REGARDING THE SERVICES PROVIDED. THIS AUTHORIZATION WILL EXPIRE IN ONE YEAR FROM THE DATE OF MY REVOCATION IS RECEIVED AND PROCESSED. I UNDERSTAND THAT IF ANY INSURER DOESN'T PAY AND DENIES THE CLAIM AS AN UNCOVERED SERVICE, I AM RESPONSIBLE FOR PAYMENT IN FULL. IF MY INSURER PAYS ME DIRECTLY, I AGREE TO ENDORSE THE CHECK AND FORWARD IT TO THE LABORATORY WITHIN 30 DAYS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNTS NOT TO BE PAID BY INSURER FOR REASONS INCLUDING, BUT NOT LIMITED TO, NON- COVERAGE, NON-PARTICIPATING PROVIDER/PHYSICIAN AND NON-AUTHORIZED SERVICES.
I, DO HEREBY ALLOWED, CAPSTONE CLINICAL LABS OR A CLIA-CERTIFIED LABORATORY, TO ACT AS MY FINANCIAL REPRESENTATIVE IN REQUESTING, A COMPLIANT, AN APPEAL AND DOCUMENTS FROM MY INSURANCE PROVIDER REGARDING THE SERVICES PROVIDED. I, AUTHORIZATION FOR ASSIGNMENT OF BENEFITS I, THE UNDERSIGNED, AUTHORIZE MY INSURANCE TO MAKE PAYMENT FOR BENEFITS DUE HERE INTO:
PROVIDER: Capstone Clinical Labs
I have read, understood, acknowledge and confirm that the information on this form is true and correct. I understand that the purpose of this self-health screening questionnaire is intended to help myself make decisions about seeking the appropriate medical care. By answering the questionnaire, I understand that this is only an informational tool and does not give medical advice, diagnosis, or treatment, this can be done only by a license healthcare professional.
By signing the form, I Authorize the release of medical information Protected Health Information (PHI) to share my screening questionnaire responses with a professional health care provider. I understand that my information will/can be use only to assess, diagnose, test and manage my health and well-being.
By clicking the “I agree” on Capstone telehealth portal, I understand and agree that I am signing this Consent electronically and
Telehealth involves the use of interactive electronic communications (telephone, computer, etc.) to with the patient and healthcare professional to be able to see and speak to each other remotely. This enables health care providers (doctors, nurses, physician assistants, laboratory, and others) at a different location from the patient to share medical information with that patient for the purpose of improving access to patient care. The information may be used for assessment, treatment, diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and video, Output data from medical devices and sound and video files.
The electronic systems used will attempt to incorporate security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against corruption.
As with any medical procedure, there are risks associated with the use of telemedicine. I understand and will not hold the health care professionals responsible for the following risks or can cause a delay in treatment or evaluation include, but may not be limited to:
The laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine will be disclosed to researchers or other entities without my consent.
I have the rights to discuss the risks and benefits all procedures and courses of treatment proposed by my health care provider.
I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee. Telemedicine may involve electronic communication of my personal medical information to other medical practitioners located elsewhere, including out of state.
I understand that no results from the use of telemedicine can be guaranteed or assured.