HIPAA PRIVACY AUTHORIZATION

Updated on Jan 17, 2022 

Purpose: This authorization allows our partner healthcare providers and laboratories to share your protected health information, including results of test(s) you order, with us. 

BY CLICKING ON THE “I HAVE READ AND ACCEPT THE HIPAA AUTHORIZATION” BUTTON ON THE ACCOUNT CREATION PAGE ON THE WWW.FIXEDHEALTH.AI WEBSITE, I INDICATE THAT I HAVE READ THE CONTENTS OF THIS HIPAA PRIVACY AUTHORIZATION AND I HEREBY AUTHORIZE ALL HEALTHCARE PROVIDERS, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“HEALTH CONSULTANTS”), AND THE TESTING LABORATORIES, INCLUDING THEIR PHYSICIANS, STAFF, AGENTS AND DESIGNEES (“LABS”) THAT PERFORM SERVICES REQUESTED BY OR CONSENTED TO BY ME, WHICH HAVE A RELATIONSHIP WITH FIXED TECHNOLOGIES INC (“COMPANY”), TO USE AND DISCLOSE HEALTH INFORMATION ABOUT ME IN THE MANNER AND FOR THE PURPOSES STATED BELOW. 

This authorization applies to the use and disclosure of the following information about me: all information in request(s) submitted by me or for me with my consent and the laboratory test values/results/information which are the result of such request(s). 

For avoidance of doubt, I specifically authorize the transfer and release of this information to, between and among myself and the following individuals/organizations and their representatives, affiliates, staff, agents, and designees: (a) Company; (b) the designated Company physician of record; (c) applicable Health Consultants and Labs; and (d) other Company partners for the purposes herein and as required or permitted by law. 

The information subject to this authorization may be used or disclosed for the following purposes: (a) to facilitate and execute the services requested by me or performed with my consent (including receiving, reviewing, and approving test requests and reviewing, processing, and delivering the test values/results); (b) for treatment, health care operations and payment services; (c) to provide me with information and materials on treatment alternatives, health related offerings and services and products which may assist me with health, wellness and overall care or be of interest to me; (d) to conduct statistical research studies; and (e) as required or permitted under applicable state and federal laws. I authorize the use of my personal information for marketing purposes, including providing information about products and services that may be of interest to me. 

I may opt to not have my personal information used or disclosed for some of the purposes above. In order to opt-out, I must provide written notice to the Company as set forth below. I understand that such opt-out may affect the services I have voluntarily elected to receive. 

This authorization is evidence of my informed decision to allow the release of my information to the parties referenced above. This authorization is effective immediately and will expire ten years after the date of this authorization. Upon my written request, I may inspect or copy the information that I have permitted to be used or disclosed, as permitted by law. 

I understand that I have a right to receive a copy of this authorization. I have the right to refuse to agree to this authorization and understand that my refusal may affect the services provided to me. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and would then no longer be protected by federal privacy regulations. 

I may revoke this authorization in writing at any time. I understand that my revocation will not affect any use or disclosure already taken in reliance upon this authorization. My written revocation must be submitted to Company by Email: privacy@stayfixed.com. 

I understand that this authorization may be accepted by someone legally authorized to represent me. 

I have read this document carefully, and all my questions were answered to my satisfaction. I hereby consent to participate in the telehealth visit with my selected healthcare practitioner(s) pursuant to the terms, conditions, standards, and requirements set forth herein or as otherwise provided to me.