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AUTHORIZATION TO USE AND DISCLOSE MY HEALTH INFORMATION
By signing this Authorization, I am authorizing my health care providers, my pharmacies, physicians, other health care providers, health plan(s), health insurers, and the agents and contractors of any of these entities (collectively, “Health Care Entities”), to use and disclose to ScriptHero LLC (d/b/a the “ScriptHero Marketplace") and its affiliates (collectively “ScriptHero”) My Health Information (as described below) for ScriptHero to use and disclose such information for the following purposes:
- To facilitate my treatment and health care (e.g., providing information about my one or more health and medical conditions (“Conditions”));
- To send me, or permit business affiliates to send me, information about products and services that may be of interest to me, including:
- Offers, products or services available from ScriptHero or third parties, such as discount card vendors or pharmaceutical manufacturers;
- Surveys from ScriptHero or third parties (e.g., pharmaceutical manufacturers) about products and services related to my Condition(s);
- Programs to help me pay for or remain adherent to my medications or that provide support and information regarding my medications and Conditions;
- To operate ScriptHero and provide its services, including, but not limited to:
- Administering any programs or services it offers on its own behalf or on behalf of discount card vendors or pharmaceutical manufacturers;
- Provide customer service;
- Establish, service and perform operations related to my online profile on ScriptHero’s website(s) or mobile application(s); and
- Perform other internal operations; and
- Improve the ScriptHero website(s), mobile application(s), products or services or develop new products and services, and to perform surveys (including surveys directed to my Health Care Entities), market research and other data analytics and share the results with third parties (e.g., pharmaceutical manufacturers).
My Health information that will be used and disclosed, as described in this Authorization, includes, but is not limited to, my name, demographic (e.g., gender and date of birth), contact information, device information, insurance information, and information about my Conditions, treatment, diagnoses, and medications (“My Health Information”). I understand that My Health Information may include my entire medical record and information about my mental health, alcohol and drug abuse, family planning and pregnancy, communicable diseases, HIV/AIDS, sexually transmitted diseases, genetic testing and information, and developmental disabilities, as applicable.
Remuneration and Redisclosure: I understand that my Health Care Entities may receive payment or other remuneration from third parties for disclosing My Health Information, as described in this Authorization. I understand that, once any of my Health Care Entities disclose My Health Information to ScriptHero based on this Authorization, My Health Information may no longer be protected by applicable federal and state privacy laws and may be re-disclosed by the person or entity who receives it.
My Rights with Respect to this Authorization: I understand:
- This Authorization is voluntary. My refusal to sign this Authorization will not affect my ability to obtain treatment services from my physician practice, pharmacy or other health care providers, receive payment, enroll in a health plan, or be eligible for benefits. However, I understand that I may not be able to obtain ScriptHero’s full functionality and services if I do not sign the Authorization.
- I have the right to withdraw or revoke my Authorization at any time by contacting email@example.com.
- My revocation typically will be processed by ScriptHero within 2 business days.
- My revocation will not be effective for uses and disclosures of My Health Information that may have occurred prior to the processing of my revocation of this Authorization.
- I have been given or provided the opportunity to save, print, copy or otherwise obtain a copy of this Authorization.
- Unless I revoke this Authorization before then, this Authorization will expire one (1) year after the date I sign or otherwise execute it.
BY AGREEING TO THIS AUTHORIZATION, I UNDERSTAND THAT MY HEALTH INFORMATION MAY BE USED AND DISCLOSED AS DESCRIBED IN THIS AUTHORIZATION.
If signed by the Patient's Legal Representative: Please prescribe the authority to act on the patient’s behalf.
I certify I am the Legal Representative of the individual who is the subject of this Authorization and authorized to sign this consent on behalf of that individual.