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AUTHORIZATION OF BIOFOURMIS / COPILOTIQ TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION



    Date of Birth (MM/DD/YYYY):

    /

    /

    INFORMATION TO BE DISCLOSED:

    The information that may be disclosed under this Authorization includes office notes, lab/diagnostic testing results, and hospital records. Please refer to cover sheet for detailed information regarding this specific request.

    RECIPIENT ADDRESS:

    COPILOTIQ/BIOFOURMIS

    Fax: 833-464-5468

    TERM

    From the date of this authorization until 1 year from date signed, request is withdrawn by member, or member is disenrolled from the program.

    PURPOSE: I authorize the Company to use or disclose my health information during the term of this Authorization for the following specific purpose(s): To facilitate coordination of care among healthcare providers and to support ongoing medical management, including treatment planning, medication management, referrals, and communication between my care team members to ensure continuity and quality of care.

    I understand that once Company discloses my health information to the recipient, Company cannot guarantee that the recipient will not re-disclose my health information to a third party. Further, the third party may not be required to abide by this Authorization or applicable federal law governing the use and disclosure of my health information. However, if my information includes alcohol or drug abuse treatment program records or information, the confidentiality of the records or information is protected by federal law (42 C.F.R. Part 2) that prohibits re-disclosure except with my specific written consent.

    I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment at the Company; except, however, if my treatment at the Company is for the sole purpose of creating health information for disclosure to the recipient identified in this Authorization, in which case the Company may refuse to treat me if I do not sign this Authorization.

    I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to the Company's Privacy Office at the address listed below. The revocation will be effective immediately upon the Company's receipt of my written notice, except that the revocation will not have any effect on any action taken by the Company in reliance on this Authorization before it received my written notice of revocation.

    I may contact the Company's Privacy Officer by telephone at (800)930-5144 or by email at privacy.officer@copilotiq.com.

    I understand that I have a right to receive a copy of this authorization.

    Is the patient a minor or otherwise unable to sign this form?