HIPAA Authorization & Consent 

AUTHORIZATION, CONSENT, AND RELEASE TO USE AND DISCLOSE HEALTH INFORMATION (“Consent”)
 

I authorize my health care provider, whom I identify in the sign-up process, and Elixir Health, LLC (“Elixir”) to use and disclose health information about me through the ArtemisCalendar application (the “App”) that permits communications between and among my health care provider, Elixir, and me. The health information to be used, disclosed, and shared under this Consent includes my name, contact information, date of birth, gender, diagnosis, treatment and dosing information, provider notes and instructions, health symptoms, appointment and treatment reminders, and other hormone replacement therapy information (“Health Information”). The purpose of this Consent is to facilitate communications between my health care provider and me and is as I request. I acknowledge and agree:

 

  • I may refuse to sign this Consent. My refusal will not affect my treatment, payment for services, enrollment in a health plan, or eligibility for benefits, but if I refuse, then I will not be able to use the App.

  • I have the right to revoke or withdraw this Consent at any time, except for actions already taken in reliance on this Consent. I may revoke this Consent by choosing to close my account and delete all Health Information and other associated data from the Settings page within the App.

  • Unless earlier revoked, this Consent will expire automatically when I choose to close my account and delete all Health Information and other associated data from the Settings page within the App

  • The Health Information shared under this Consent potentially may be redisclosed by a recipient and may not be protected by federal or state privacy laws, except my health care provider would continue to be subject to confidentiality laws.

  • I may have a copy of this Consent after I electronically sign it by accessing it from the Settings page within the App. I can view the Health Information subject to this Consent through the App.

 

I have read and understand this Consent. I voluntarily agree to this Consent:

 
 
Signature: _____________________________________________                              Date:__________________________________

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