HIPAA Authorization to Use Protected Health Information

I hereby authorize InteliChart, on behalf of any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility or other health care provider, to use any and all protected health information (“PHI”) included in my medical record maintained by InteliChart, including any information entered by me during a check-in process and/or in InteliChart’s patient engagement applications and services. InteliChart will not disclose any of my PHI to any third party and will use my PHI consistent with this Authorization, as set forth below.
I understand that my PHI may be used for marketing purposes, including the delivery of (i) targeted, health-related materials (including educational materials), information, newsletters and sponsored content related to treatments and therapies specific to my health status, (ii) patient reminders for visits, and (iii) medication/treatment adherence and other medical practice-related services. The foregoing materials may be provided by my health insurance plan, a pharmaceutical manufacturer or another healthcare entity to InteliChart to provide to me and/or any other representative, agent or proxy that I designate or permit to access and view my PHI. In some instances, InteliChart will receive payment from third parties in connection with use of your PHI, as described in this Authorization.
This Authorization shall remain in effect until the first anniversary of the date of your signature of this Authorization OR I provide written notice of revocation of this Authorization in accordance with Section 5 below.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this Authorization, and that I have the right to refuse to sign this Authorization.
I understand that, as set forth in the notice of privacy practices, I have the right to: (i) revoke this Authorization, in writing, at any time, except to the extent that InteliChart has acted in reliance upon it, (ii) update any of my information, and/or (iii) request a paper copy of this Authorization at a nominal fee, in each case by sending written notification to: [Contact Information]
I agree to enter into this Authorization electronically and that by checking the box "I AGREE," I am confirming my intent to be bound by the terms of the Authorization and that shall be treated as my electronic signature. Further, I understand and agree that such electronic signature is intended to authenticate this Authorization and to have the same force and effect as a manual signature, to the extent and as provided for under applicable state and federal law, including without limitation the Electronic Signatures in Global and National Commerce Act of 2000 and the Uniform Electronic Transactions Act (UETA), for purposes of validity and enforceability.
I understand I will receive an electronic copy of this signed Authorization.
If I am a personal representative signing this Authorization on behalf of one or more individuals identified below, including (if applicable) an unemancipated minor, I hereby represent that I am authorized to sign this Authorization on behalf of each such individual based upon the “Capacity” designation below, and I acknowledge the PHI permitted to be used pursuant to this Authorization is limited solely to the PHI of each such individual for which I am deemed such individual’s personal representative in accordance with HIPAA.

[Date Stamp]

_______________________________________
Patient Name

_______________________________________
Personal Representative Name

Child or Dependent

Please provide the following information about the child or dependent.

Parent or Guardian

For your security, please choose a password, security question & answer.

Aviso legal