HIPAA Authorization to Use and Disclose Protected Health Information
Under the Health Insurance Portability and Accountability Act (HIPAA), some health and health-related information may be considered “protected health information” or “PHI” if such information is received from or on behalf of healthcare professionals and health-oriented service providers (collectively, “Providers”). This authorization allows Gezoont LLC (“Gezoont”) to use and/or disclose my PHI as set forth below.
1. I hereby authorize Gezoont to use and/or disclose the protected health information about me described below (“PHI”) to:
(a) third parties assisting Gezoont with the operation or provision of our services or any of the purposes described under Section 3;
(b) your Providers;
(c) a third party as part of a merger, sale, acquisition, or other change of control event of Gezoont;
(d) a provider of medical services, in the event of an emergency; and
(e) as otherwise required by law.
2. The PHI that may be used and/or disclosed is: All PHI.
3. The PHI may be used and/or disclosed to:
(b) provide you information about your appointments;
(c) notify you about Providers you may be interested in;
(d) market to you regarding the Services and/or resources we think might interest you;
(e) share information with you regarding the Services and the Site, including information about updates;
(f) develop and improve the Site and Services;
(g) conduct analysis for Gezoont’s business purposes;
(h) provide information to your Providers or entities that assist them with processing your information; and
(i) create anonymized information and then lawfully use and disclose this information, including in connection with their marketing efforts of certain third parties.
4. This authorization shall remain in effect until you no longer use the Gezoont’s Site or Services. If you revoke or do not sign this authorization, you cannot use the site or services.
5. I understand that, as set forth in the notice of privacy practices, I have the right to revoke this authorization, in writing, at any time, except to the extent that Gezoont has acted in reliance upon it, by sending written notification to: firstname.lastname@example.org.
6. I understand that I have the right to refuse to sign this authorization, in which case I will not be able to use Gezoont.
I understand that PHI used or disclosed pursuant to this authorization may be redisclosed by the recipient and its confidentiality may no longer be protected by federal or state law.
I have read and agree to this HIPAA Authorization form, which will allow Gezoont LLC to use and disclose my PHI in accordance with the terms set forth above.