HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information. I hereby authorize all health care providers (“Health Advisors”) and testing laboratories (“Testing Labs”) that provide services to me in connection with my subscription to services provided by Wellbody, LLC. (“Wellbody”) to use and/or disclose the protected health information described below to Wellbody as follows. Authorization for Release of Information. I hereby authorize the release of my complete health record contained in my account with Wellbody (including without limitation all Health Advisor notes and diagnoses and Testing Labs results and the information I have contributed to my health record contained within my account), covering all past, present and future periods. This health information may be used by Wellbody in order to provide the Wellbody services that I subscribed to and for any other uses that I consent to from time to time pursuant to the policies and agreements applicable to my subscription to services provided by Wellbody. This authorization shall be in force and effect until I revoke it in accordance with the terms below. I understand that I have the right to revoke this authorization at any time by providing written notice to email@example.com. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I further understand that, upon my revocation, my Health Advisors and Testing Labs will no longer be able to disclose my health information to Wellbody, and that the Wellbody services therefore will no longer be available to me. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization. However, I understand that failure to provide this authorization will prevent my Health Advisors and Testing Labs from disclosing my health information to Wellbody, and that the Wellbody services therefore will not be available to me. 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. I understand I have the right to receive a copy of this authorization by sending a written request to firstname.lastname@example.org.
Date of Last Revision: May 2018