Everlywell Authorization for Release of PHI
Last Modified: May 18, 2020
Purpose This authorization allows our partner healthcare providers and laboratories to share certain protected health information, described below, including results of test(s) you order, with us.
BY CLICKING ON THE “I HAVE READ AND ACCEPT THE AUTHORIZATION FOR RELEASE OF PHI” BUTTON ON THE ACCOUNT CREATION PAGE ON THE EVERLYWELL.COM WEBSITE AND/OR BY SENDING IN MY SAMPLE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS AUTHORIZATION FOR RELEASE OF PHI AND I HEREBY AUTHORIZE ALL HEALTHCARE PROVIDERS, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“HEALTH CONSULTANTS”), AND THE TESTING LABORATORIES, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH EVERLY WELL, INC. (“COMPANY”), TO USE AND DISCLOSE HEALTH INFORMATION ABOUT ME IN THE MANNER AND FOR THE PURPOSES STATED BELOW.
This authorization applies to the use and disclosure of the following information about me: all information in request(s) submitted by me or for me with my consent and the laboratory test values/results/information which are the result of such request(s).
For avoidance of doubt, I specifically authorize the transfer and release of this information to, between and among myself and the following individuals/organizations and their representatives, affiliates, staff, agents, and designees: (a) Company; (b) your insurance company; (c) any physician that you designate; (d) applicable Health Consultants and Labs; and (e) other Company partners for the purposes herein and as required or permitted by law.
The information subject to this authorization may be used or disclosed for the following purposes: (a) to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing, and approving test requests and reviewing, processing, and delivering the test values/results); (b) for treatment, health care operations, and payment services; (c) to conduct statistical research studies using de-identified test results; and (d) as required or permitted under applicable state and federal laws. I may opt to not have my personal information used or disclosed for some of the purposes above. In order to opt-out, I must provide written notice to the Company as set forth below. I understand that such opt-out may affect the services I have voluntarily elected to receive.
This authorization is evidence of my informed decision to allow the release of my information to the parties referenced above. This authorization is effective immediately upon sending in my sample or clicking the button on the authorization page, and will expire ten years after the date of this authorization. Upon my written request, I may inspect or copy the information that I have permitted to be used or disclosed, as permitted by law.
I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization and understand that my refusal may affect the services provided to me. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and would then no longer be protected by federal privacy regulations.
I may revoke this authorization in writing at any time. I understand that my revocation will not affect any use or disclosure already taken in reliance upon this authorization. My written revocation must be submitted to Company using the contact information below.
To opt not to have your personal information used or disclosed for some of the purposes above, to request written inspection of the information you have permitted to be used or disclosed, or to submit a written revocation of this authorization, contact the Company at: Everly Well, Inc., 823 Congress Ave, Suite 1200, Austin, TX 78701; Email: [email protected].
I understand that this authorization may be accepted by someone legally authorized to represent me.
NOTICE OF PRIVACY PRACTICES AND RELEASE OF MEDICAL INFORMATION
I agree to have healthcare practitioner(s) affiliated with PWN Remote Care Services (“Practice”), an independent telehealth service, contact me regarding my tests and test results. Because the practice is a telehealth service, I understand that the healthcare practitioner(s) providing services to me may utilize the PWN telehealth platform, which is remote from my location, to contact me.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the course of the telehealth consultations with the Practice which identifies me will be disclosed to non-covered entities, as defined in HIPAA, without my written consent.
I acknowledge and understand that
- This is a copy of the Practice’s “Notice of Privacy Practices”.
- This Notice of Privacy Practices is intended to provide information about how Practice and its healthcare providers and contractors may use and/or disclose protected health information about me.
- Details on Practice’s Privacy Practices can be obtained by contacting the Practice’s Privacy Officer at 123 W 18TH Street, New York, NY 10011, through the information in this Notice, and with respect to additional information provided to you to the Practice.
- Practice may release information obtained as a result of the telehealth services to my other healthcare providers, my healthcare insurer or other payer, Everly Well, Inc., or as otherwise provided in this Notice of Privacy Practices.
- Practice cannot be responsible for use or re-disclosure of information by third parties.
- My personal medical information obtained through telehealth consultations may be communicated to other medical practitioners who may be located in other areas, including out of state.
- My healthcare information may be shared with other individuals for scheduling, billing, treatment or operational purposes, including sharing my information with PWNHealth, LLC and applicable laboratories or pharmacies.
I acknowledge and understand that by agreeing to the telehealth services
- I authorize PWNHealth, LLC and Practice to use my email address and phone number for health-related messaging purposes.
- PWNHealth, LLC and Practice value patient privacy and do not sell email addresses or phone numbers or use them for purposes other than those outlined herein.
- I can revoke this authorization using the Everlywell contact information listed above and opt-out of such messaging uses at any time after receiving the initial communication from PWNHealth, LLC or Practice.
- Neither PWNHealth, LLC nor Practice has conditioned my treatment on the provision of these authorizations. The information provided is correct to the best of my knowledge. I will not hold PWNHealth, LLC, Practice or its health care providers, or either of their employees responsible for any errors or omissions that I may have made in completing this form.
I have read this document carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in this testing program pursuant to the terms, conditions, standards, and requirements set forth herein or as otherwise provided to me.