Authorization for the release of Protected Health Information
I hereby authorize the use and/or disclosure of my protected health information (“PHI) as described below:
I authorize the following PHI to be used and/or disclosed pursuant to this authorization: For purposes of enhancing my diet/wellness services.
I authorize the following entities to make the disclosure of my PHI: any professional provider affiliated with American Well Corporation (“Amwell”).
I authorize the following person(s), or class of persons, to receive my PHI: Digital Wellness, US, LLC.
My PHI will be used or disclosed for the following purpose(s): To enhance diet/wellness services provided to me including, if applicable, tailoring my diet, depending upon which medication I am prescribed.
I understand that, if my PHI is disclosed to someone who is not required to comply with the federal privacy protection regulations, then such information may be re-disclosed and would no longer be protected.
I understand that I have a right to revoke this authorization at any time. My revocation must be in writing and must be sent to the Privacy Officer at [email protected]. I am aware that my revocation will not have any effect on any actions taken by the persons I have authorized to use and/or disclose my PHI before they receive my revocation.
This authorization expires upon the earlier of (a) my revocation of the authorization or (b) five (5) years from the date of my execution of this authorization form.
I certify that I have received a copy of this authorization for my records.