HIPAA AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Description of Platform Service
Uniq Health LLC (“Uniq”) is the owner of Tuune 360, a clinical decision support tool that supports patients and health care professionals with educational information that can assist in choosing contraceptive options. Uniq also owns and operates the Tuune digital telemedicine platform (the “Tuune Platform”) that facilitates the provision of medical services by medical professionals to users of the Tuune Platform (“Users”). Users may also have prescriptions for contraceptives electronically sent to pharmacies through the Tuune Platform and may obtain laboratory services through the Tuune Platform. As part of operating the Tuune Platform on behalf of you, the medical professionals, the pharmacies, and the laboratories, Uniq requires access to your medical, prescription, and laboratory reports and records. Accordingly, users of the Tuune Platform are required to authorize the use and disclosure of their personal health information by and among Uniq, medical professionals, pharmacies, and laboratories. You are not required to sign this HIPAA Authorization, but you will not be able to access and utilize the services offered by the Tuune Platform without signing this HIPAA Authorization.
I hereby authorize Uniq LLC (“Uniq”) to use and disclose my protected health information (“PHI”) that I provide through the Tuune Platform, including health assessments, to medical professionals, laboratories, and pharmacies who provide services to me through the Tuune Platform (collectively, “Providers”), and for Providers to use and disclose my PHI to each other and to Uniq in connection with services that I receive through the Tuune Platform, and to enable Uniq to provide administrative services to Providers in connection with their use of the Tuune Platform and provision of medical services to Users. This includes, for example, use and disclosure of my medical and health questionnaires, medical consultation records, prescriptions, laboratory tests and results, and correspondence between me, Uniq, and Providers. This authorization shall remain in effect until I no longer utilize the Tuune Platform. I understand that I will not receive services from Providers through the Tuune Platform unless I sign this Authorization. I understand that I have a right to revoke this Authorization, in writing, at any time, except to the extent that Uniq and Providers have acted in reliance upon it, by sending a written notification to email@example.com. I understand that PHI used or disclosed pursuant to this Authorization may be redisclosed by the recipient and its confidentiality may no longer be protected by federal or state law.
By checking this box, I attest that I authorize the use and disclosure of my PHI as described above.