Authorization

AUTHORIZATION FOR RECEIPT, USE, AND/OR DISCLOSURE OF HEALTH INFORMATION

This Authorization is effective on the date which you agree to it. Completion of this document authorizes the receipt, use, and/or disclosure of your health information as set forth below, consistent with federal and state law concerning the privacy of such health information.

USE AND DISCLOSURE OF HEALTH INFORMATION

• I authorize the receipt, use, and disclosure of my health information by Sigmoid Health Inc. (“Sigmoid”) in accordance with the Sigmoid Terms of Service and Privacy Policy.
• I authorize Sigmoid to disclose my health information to the recipients described in the Sigmoid Privacy Policy for the purposes contemplated by the Sigmoid Terms of Service and/or Privacy Policy or the purposes contemplated by my relationship with the recipient. I understand that some of these recipients may be limited in how they can use my health information.
• I understand that if Sigmoid's use of my health information is subject to the Health Insurance Portability and Accountability Act and governed by a business associate agreement Sigmoid has entered into with a clinician or a practice, Sigmoid will use my health information in accordance with the business associate agreement. However, if Sigmoid is directed by me to use my health information outside of the direct relationship with the clinician or practice, either through a written statement or through my use of Sigmoid's services, I authorize the clinician or practice to disclose my health information to Sigmoid. In such case, my health information will be subject to this Authorization, not the business associate agreement.
• This Authorization applies to all my health information which Sigmoid processes in connection with my Sigmoid account including information pertaining to my medical history, mental or physical condition and treatment received (including mental health records protected by state law, genetic test results, drug and/or alcohol abuse records and/or HIV test results) other than psychotherapy notes.

EXPIRATION

This Authorization expires once I delete my account and Sigmoid has completed this deletion process.

YOUR RIGHTS

This Authorization is voluntary. Treatment, payment or eligibility for benefits may not be conditioned on execution of this Authorization, except as set forth in 45 C.F.R. § 164.508.

I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to Sigmoid. My revocation will be effective upon receipt, but will not be effective to the extent that Sigmoid or others have acted in reliance upon this Authorization.

I have a right to receive a copy of this Authorization.

Information received or disclosed pursuant to this Authorization is subject to redisclosure by the recipient and will no longer be protected information under 45 C.F.R. § 164.508 or under California Civil Code § 56.10 - 56.16.