HIPAA Release Form
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:
- This authorization may include disclosure of information relating to alcohol and drug treatment and mental health treatment. The protected health information is released for the purpose as described in section 1 below.
- With some exceptions, health information once disclosed may be redisclosed by the recipient as described in section 5 below.
- I have the right to revoke this authorization at any time as described in section 6 below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
- Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.
1. Purpose of Release of Information
Circady offers services, such as helping you to find and connect with Sleep Specialists (“Service Provider”), providing Telehealth services and providing a digital sleep diary (“Services”).
As part of providing these Services, Circady may collect, use, share, and exchange your health history forms and other health-related information with Service Providers. Under a federal law called the Health Insurance Portability and Accountability Act (“HIPAA”), some of this health and health-related information may be considered “protected health information” or “PHI” if such information is received from or on behalf of Your Healthcare Providers.
2. Safeguards for PHI
HIPAA protects the privacy and security of your PHI by limiting the uses and disclosures of PHI by most healthcare providers and by health plans (called “Covered Entities”) as well as companies, like Circady, that provide certain types of assistance to Covered Entities (called “Business Associates”). HIPAA requires that under certain circumstances, an individual (a user) needs to sign an Authorization form before a Covered Entity (e.g. your Service Provider(s)), can disclose protected health information to a third party.
3. Non-Protected Health Information
4. Your PHI Authorization
The purpose of this HIPAA Authorization (“Authorization”) is to request your written permission to allow Circady to use and disclose your PHI in the same way as we use and disclose your Non-PHI. If Circady is a Business Associate of your Service Providers, Circady needs your Authorization to be able to use and disclose your PHI in the same way it can currently use and disclose your Non-PHI when Circady is not working on behalf of your Service Providers, but is instead working on its own behalf. Therefore, when Circady relies on this Authorization, and uses and discloses PHI as described in this Authorization, it is not working as a Business Associate and the HIPAA requirements that apply to Business Associates will not apply to such uses and disclosures.
By signing this Authorization, you give your permission to Circady to retain your PHI and to use and/or disclose your PHI in the same way that you have agreed that your Non-PHI can be used and disclosed.
Specifically, you agree that Circady can use your PHI to:
- enable and customize your use of the Circady Services;
- provide you reminders or other Circady Services regarding future appointments;
- notify you regarding providers we think you may be interested in learning more about;
- share information with you regarding services, products or resources about which we think you may be interested in learning more;
- provide you with updates and information about the Circady Services;
- market to you about Circady and third party products and services;
- conduct analysis for Circady’s business purposes;
- support development of the Circady Services; and
- create de-identified information and then use and disclose this information in any way permitted by law, including to third parties in connection with their research and development or commercial and marketing efforts.
You also agree that Circady can disclose your PHI to:
- third parties assisting Circady with any of the uses described above;
- your Service Provider(s) to enable them to refer you to, and make appointments with, other providers on your behalf, or to perform an analysis on potential health issues or treatments, provided that you choose to use the applicable Circady Service;
- a third party as part of a potential merger, sale or acquisition of Circady;
- our business partners who assist us by performing core services (such as hosting, billing, fulfillment, or data storage and security) related to the operation or provision of our services, even when Circady is no longer working on behalf of your Service Provider(s);
- a provider of medical services, in the event of an emergency; and
- organizations that collect, aggregate and organize your information so they can make it more easily accessible to your providers.
If Circady discloses your PHI, Circady will require that the person or entity receiving your PHI agrees to only use and disclose your PHI to carry out its specific business obligations to Circady or for the permitted purpose of the disclosure (as described above). Circady cannot, however, guarantee that any such person or entity to which Circady discloses your PHI or other information will not re-disclose it in ways that you or we did not intend or permit.
6. Expiration and Revocation of Authorization
Your Authorization remains in effect until you provide written notice of revocation to Circady which you can do at any time.
If you wish to revoke this Authorization, you must notify Circady by submitting a request to email@example.com.
Your decision not to execute this Authorization or to revoke it at any time will not affect your ability to use certain of the Circady Services. A Revocation of Authorization is effective after you submit it to Circady, but it does not have any effect on Circady’s prior actions taken in reliance on the Authorization before revoked.
Once Circady receives your Revocation of Authorization, Circady can only use and disclose your PHI as permitted in Circady’s agreements with your Service Provider(s). Your Revocation of Authorization does not affect Circady’s use of your Non-PHI.
We will make available to your Service Provider(s), current and past, your agreement to or revocation of this Authorization.