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AUTHORIZATION TO USE AND DISCLOSE MY HEALTH INFORMATION
By signing this Authorization, I am authorizing my health care providers, including ScriptHero Pharmacy, my other 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 health and medical condition);
- 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 about products and services related to my condition(s) from ScriptHero or third parties (e.g., pharmaceutical manufacturers);
- Programs to help me pay for or remain adherent to my medications or that provide support and information regarding my medications and health condition;
- 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);
- Perform other internal operations
- 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 providers), 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 my name, demographic (e.g. gender and date of birth), contact information, device information, insurance information, and information about my health, medical 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, including their contractors such as ScriptHero, may receive payment or other remuneration from third parties for disclosing My Health Information as described in this Authorization. I understand that once 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 going to the My Account tab in the ScriptHero website, (www.scripthero.com) selecting "Use of My Health Information" and selecting the desired option.
- 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 occurred prior to the processing of my revocation of this Authorization.
- I can access a copy of this Authorization in the "My Account" section of the ScriptHero website. I understand that I may print a copy of this Authorization for my records. The printed copy will have my electronic signature.
- Unless I revoke it before then, this Authorization will expire one (1) year after the date I sign it by clicking on “I consent” below.
BY CLICKING "I AGREE", I AGREE 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.