TO RELEASE PROTECTED HEALTH INFORMATION
Authorization for Use or Disclosure of Protected Health Information is required by the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 and 164.
We are committed to protecting your privacy and we take great care with your personal information that we gather when using our application. This HIPAA Authorization and Release of Protected Health Information is meant to help those that use our services understand how we treat your personal health information. BY USING OR ACCESSING OUR SERVICES IN ANY MANNER, YOU ACKNOWLEDGE THAT YOU ACCEPT THE PRACTICES AND POLICIES OUTLINED IN THIS AUTHORIZATION, AND YOU HEREBY CONSENT TO THE COLLECTION, USE, AND DISCLOSURE OF YOUR PERSONAL HEALTH INFORMATION IN THE FOLLOWING WAYS. IF YOU USE THE SERVICES ON BEHALF OF SOMEONE ELSE (SUCH AS YOUR CHILD) OR AN ENTITY (SUCH AS YOUR EMPLOYER), YOU REPRESENT THAT YOU ARE AUTHORIZED BY SUCH INDIVIDUAL OR ENTITY TO SIGN SUCH RELEASE ON THE INDIVIDUAL’S OR ENTITY’S BEHALF.
Certain demographic, health and/or health-related information that Access collects about Users as part of providing the Services offered may be considered “protected health information” or “PHI” under HIPAA. Specifically, when Access receives identifiable information about a User from or on behalf of a Healthcare Provider, and such Healthcare Provider is a “Covered Entity” (as such term is defined in HIPAA), this information is considered PHI. Personal data that a User provides to Access outside of the foregoing context is not PHI.
HIPAA provides specific protections for the privacy and security of PHI and restricts how PHI is used and disclosed. Access may only use and disclose PHI in the ways permitted by HIPAA or as authorized by the User below.
By use of the App, you authorize the disclosure of your confidential health information to Access Health and its employees and agents to use and disclose your PHI according to the provisions below. The authorization may be revoked by your express revocation delivered to Access Health. This authorization will remain until expressly revoked by you in writing. You are entitled to a copy of the complete authorization upon request. If you are a person with a disability and require this authorization in an alternative format or require a special accommodation to complete this form, you may request assistance from the Access Health staff.
I understand that by signing this document, I am authorizing access to my health conditions, current medications, and current treatments. Further, I understand that Access will disclose such information to health care providers as necessary for the continued provision of quality health care.
I understand that I am not required to sign this authorization in order to receive treatment or services from Access. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by Access. As such, I hereby attest to the following provision and request that a copy of this document be sent to (patient email address):
- I authorize the use and disclosure of my protected health information described below to Access Health.
- Effective Period. This authorization for release of information covers all past, present, and future periods of health care, including but not limited to: (1) current medications; (2) current medical treatments; (3) current health conditions.
- Extent of Authorization. I authorize the release of my complete health record, which includes but is not limited to: (1) treatment plans; (2) immunization record; (3) medical history; (4) physical history; (5) medical discharge summaries; (6) laboratory results; (7) X-ray and imaging reports; (8) consultation reports. I understand that any information disclosed may include information relating to Sexually Transmitted Diseases (STD), Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). I understand that any alcohol and/or drug treatment records are protected under Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 CFR. Part 2, and HIPAA, and cannot be disclosed without my written consent unless otherwise provided for by regulation.
- This medical information may be used by Access Health for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
- Revocation Rights. I understand that I have the right to revoke this authorization, in writing, at any time, which will be effective as soon as it is received by Access Health, except to the extent that Access Health has taken action acted in reliance on my authorization. If I do revoke this authorization in writing, it will expire one (1) year from the date listed below.
- I understand that my treatment, payment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
- I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.