Register your MISTR Kit

Please enter your kit ID and personal information to register your kit. We’ll send you an email when your results are available.

Name(Required)
Date of Birth(Required)
Sex at birth(Required)
Address(Required)
Email(Required)
Kit Acceptance(Required)
Authorization for Use of Health Information

I hereby authorize the use or disclosure of my health information as follows:

  • Persons/organizations authorized to use or disclose the information: Brightpoint Laboratories Persons/organizations authorized to receive the information: Mistr, Inc., Ash Wellness, Inc.

Purpose of requested use or disclosure: to permit Ash Wellness, Inc. to provide testing results to patient and Mistr, Inc. healthcare professional. This Authorization applies to the following information: HIV, Creatinine, Gonorrhea, Chlamydia, Syphilis, Hepatitis B, and Hepatitis C results

EXPIRATION

This Authorization expires in one (1) year.

NOTICE OF RIGHTS AND OTHER INFORMATION

I do not have to sign this Authorization. My treatment, payment for treatment, insurance enrollment, or eligibility for insurance benefits will not be directly affected if I do not sign this form.

I am entitled to a copy of this Authorization.

I may revoke (cancel) this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to the laboratory at the following address: Attn: Compliance Department, 120-08 131st St, South Ozone Park, NY 11420. My revocation will be effective upon receipt, but will not be effective to the extent that Brightpoint Laboratories, Ash Wellness, Inc., Mistr, Inc. or others have acted in reliance upon this Authorization.

I understand that under certain applicable state laws, the recipient may not re-disclose my information, except with a written authorization signed by me or as specifically required or permitted by law.

I understand that to the extent information disclosed pursuant to this Authorization is re-disclosed by the recipient, such re-disclosure may no longer be protected by federal confidentiality law (the Health Insurance Portability and Accountability Act or “HIPAA”).

MISTR Agreement(Required)