Patient Authorization for Use and Disclosure of Protected Health Information
I authorize my health care providers (including pharmacy providers) to release and disclose my personal and medical information to Cabinet Health P.B.C. and any third parties engaged by Cabinet Health P.B.C. (collectively, “Cabinet”) to facilitate the order, fulfillment, and delivery of my prescription medications in Cabinet packaging through certain electronic applications hosted by Cabinet (the “Cabinet Program”), as further described below, and I authorize Cabinet to use and disclose my information in accordance with this authorization.
Information to Be Disclosed: My protected health information (“PHI”) (as such term is defined in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and regulations thereunder), as well as other state and/or federally protected personal information, including my personal contact and other demographic information, all medical records and financial information, and information relating to my treatment, the coordination of my treatment, and the delivery, packaging, and receipt of certain medication prescribed to me (collectively, my “Information”).
Persons to Whom My Information May Be Disclosed: Cabinet, including any third parties responsible for the administration of the Cabinet Program.
Purposes for Which the Disclosures Are to Be Made: The purposes of the use and disclosure of my Information are to allow Cabinet to: (1) facilitate the order, fulfillment and delivery of my prescription medications in Cabinet packaging through certain electronic applications hosted by Cabinet (the “Cabinet Program”); (2) communicate with my health care providers about my prescription medications and medical care; (3) provide appropriate information and prescription management support through Cabinet’s electronic application chat functions, including promotional or educational communications; (4) contact me regarding this authorization or my use or potential use of my prescriptions and providing me with related communications, including through messages left for me that disclose that I take or may take certain prescription medications; and (5) administer, evaluate, and improve the Cabinet Program, including analyzing the usage patterns and the effectiveness of Cabinet’s services and helping to develop new products, services, and programs, and for other Cabinet general business and administrative purposes.
I understand that certain entities may receive remuneration for the use or disclosure of my Information, as authorized above, and that, once my Information has been disclosed to Cabinet, my Information may not be subject to all of the protections and safeguards provided by HIPAA or other federal and state privacy laws. I also understand, however, that Cabinet plans to use and disclose my Information only for the purposes described above or as required by law.
I understand that I may refuse to sign this Authorization and that my refusal to sign this Authorization will not affect my right to treatment or payment of benefits for health care. I understand that if I refuse to sign, I will not be eligible to receive support through Cabinet.
I may later withdraw this Authorization by sending written notice of my withdrawal from Cabinet to firstname.lastname@example.org. Withdrawal of this Authorization will end further uses and disclosures of my Information by Cabinet, except to the extent those uses and disclosures have been made in reliance on this Authorization and as permitted by applicable law. I am entitled to receive a copy of this signed Authorization, which expires the earlier of one (1) year from the date it is signed by me, unless otherwise specified by law or revoked earlier in writing.