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AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
Completion of this document authorizes the disclosure and/or use of individually identifiable health information, set forth below, consistent with federal and applicable state law concerning the privacy of such information.
USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize the disclosure of all medical records related to my sleep apnea consultation, including the results of any sleep tests, diagnosis information, and copies of prescriptions, if any, by my sleep apnea and/or home sleep test health care provider (“Provider”) to Whole You for the purpose of assessing my need for a Whole You Sleep Appliance for the treatment of sleep apnea.
This Authorization applies to the following information: my name and contact information, including mobile or other telephone number, email address, and home address (including city, state, and zip code); birth date; medical records related to my sleep consultation, including results of any sleep tests, diagnosis, and any prescriptions related to treatment for sleep apnea.
Unless previously revoked, this Authorization expires three (3) years from the date of electronic signature.
NOTICE OF RIGHTS AND OTHER INFORMATION
I may refuse to sign this Authorization. Refusal to sign this Authorization will not adversely affect my ability to receive health care services or reimbursement for health care services.
However, if I refuse to sign this Authorization, Whole You will be unable to arrange for sleep apnea and/or a sleep test on my behalf.
I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to Provider at Provider’s place of business, in person or by U.S. mail or courier service. My revocation will be effective upon receipt, but will not affect previous disclosures made in reliance upon this Authorization.
I have a right to receive a copy of this Authorization.
Information disclosed pursuant to this Authorization could be re-disclosed by the recipient. Such re-disclosure may no longer be protected by federal confidentiality laws, including the Health Insurance Portability and Accountability Act (“HIPAA”), or by state medical record and/or privacy laws.
An “electronic signature” refers to the act of attaching a signature by electronic means. By providing my signature electronically, I intend to demonstrate my authorization to the release of my individually identifiable health information, as outlined in this Authorization Form. I understand that my electronic signature has the same legal effect as an original signature on a paper document. I also understand that I may request a copy of this Authorization Form from my Provider.
Please enter your information
If this Authorization has been prepared by a personal representative (such as a parent or guardian) on behalf of the individual, complete the following:
I am a resident of the state of California
Category A, Identifiers; Category B, Customer Records; Category G, Geolocation Data.
We collect the above Identifiers, Customer Records, and Geolocation Data to create an account to have a provider in your area contact you concerning the information you have requested. We also use your information to follow-up with you to see if we can provide you with any additional information that you may need about our products and services.