FitnessDx (NeuCare, LLC)
HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164 and California Civ. Code § 56.11)
1. I hereby authorize NeuCare LLC (“NeuCare”) and any associated testing laboratories and services (“Testing Labs”) that provide services to me in connection with participation in FitnessDx to use and/or disclose the protected health information described below to NeuCare as follows.
2. Authorization for Release of Information. I hereby authorize the release of my complete health record contained in my account with NeuCare (including body measurements and Testing Labs results), covering all past, present and future periods.
3. This health information may be used by NeuCare in order to provide FitnessDx services that I subscribed to and for any other uses that I consent to from time to time pursuant to the policies and agreements applicable to my participation in FitnessDx services.
4. This authorization shall be in force and effect until I revoke it in accordance with the terms below.
5. I understand that I have the right to revoke this authorization at any time by providing written notice to email@example.com. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I further understand that, upon my revocation, that NeuCare will no longer be able to disclose my health information to any associated “Testing Labs”, and that the FitnessDx testing therefore will no longer be available to me.
6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization. However, I understand that failure to provide this authorization will prevent Testing Labs from disclosing my health information to NeuCare, and that the FitnessDx services therefore will not be available to me.
7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
8. I understand I have the right to receive a copy of this authorization by sending a written request to firstname.lastname@example.org.