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HIPAA Authorizations

Lyv Health, Inc.

Authorization for Disclosure of Protected Health Information

 

I hereby authorize the laboratory, medical group, or other covered entity healthcare provider identified below (the “Disclosing Provider”) to disclose my protected health information to Lyv Health, Inc. (“Lyv Health”) and my Wellness Partner(s) identified below the ability to access my protected health information through the Lyv Health platform interface (the “Platform”), for care coordination purposes. I understand that this Authorization for Disclosure of Protected Health Information (“Authorization”) is voluntary, and I may refuse to sign this Authorization. My refusal to sign, or my revocation of this Authorization, will not affect my eligibility for any treatment, payment, benefits, or services that I am otherwise entitled to receive or participate in. If I decline to sign this Authorization, the Disclosing Provider may not be able to share certain health information with Lyv Health, limiting the ability of Lyv and my Wellness Partner to access certain health information that may be relevant to Lyv’s ability to provide care coordination services and the Wellness Services I receive through the Platform.

 

“Protected health information” referred to in this Authorization means protected health information as that term is defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). HIPAA defines “protected health information” as identifiable information relating to (a) my past and present physical or mental health or condition; (b) the provision of health care to me; and (c) payment for the provision of health care to me. Protected health information may include information created both before and after the date of this Authorization. Please note that certain sensitive categories of protected health information are expressly excluded from this Authorization and will not be disclosed to Lyv Health or my Wellness Partner under any circumstances, as described in the notice below.

 

PROTECTED HEALTH INFORMATION TO BE DISCLOSED

Health Reports and Wellness Assessments

Lab and Diagnostic Test Results

Prescription Information and Prescription Orders

 

NOTICE: SENSITIVE HEALTH INFORMATION IS EXCLUDED FROM THIS AUTHORIZATION. To protect your privacy, this Authorization does not cover, and neither the Disclosing Provider nor Lyv Health will disclose, the following sensitive categories of protected health information, regardless of the selections made above: (i) Mental health and psychiatric records, including any records protected under 42 C.F.R. Part 2 (substance use disorder treatment records); (ii) HIV/AIDS status, testing, diagnosis, or treatment records; (iii) Reproductive health information, including records relating to abortion, contraception, fertility treatment, or pregnancy; and (iv) Genetic information. For questions about how Lyv Health handles sensitive health information, please contact Lyv Health at hello@lyvhealth.co or by mail at 199 N Harvard St, N605, Boston, MA 02134, Attn: Privacy Officer.

 

DISCLOSING PROVIDER INFORMATION

 

I authorize the following laboratory, medical group, or other covered entity healthcare provider to disclose the categories of protected health information selected above to Lyv Health, Inc.,
Email: hello@joinlyv.com 

Name of Disclosing Provider: Hinds4Health

 

 

WELLNESS Partner INFORMATION

 

I authorize Lyv Health to make the categories of protected health information selected above available for limited access, solely through the Platform, to my Wellness Partner currently active on the Platform to whom I am assigned or with whom I engage for Wellness Services, while such Wellness Partner(s) are actively logged in to the Platform.


PURPOSE OF THE DISCLOSURE

Care coordination and treatment services provided to me through the Platform by Lyv Health

Provision of Wellness Services to me through the Platform by my designated Wellness Partner(s)

 

Further, if I am a resident of California, any person or entity to whom my protected health information is disclosed pursuant to this Authorization may not further use or disclose the protected health information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by applicable law.

 

I understand that I may revoke this Authorization at any time by: (a) sending a written revocation notice to: (i) the Disclosing Provider identified above at the address provided; and/or (ii) Lyv Health at hello@joinlyv.com Attn: Privacy Officer; or (b) logging into my account on the Platform and updating my authorization settings. My revocation will be effective upon receipt by the Disclosing Provider and/or Lyv Health, except to the extent that the Disclosing Provider, Lyv Health, or my Wellness Partner has already acted in reliance on this Authorization prior to receipt of my revocation.

 

I acknowledge that I have read and understand this Authorization for Disclosure of Protected Health Information. I understand that I have a right to receive a copy of this Authorization upon request. This Authorization shall expire upon the earliest of: (i) the date on which my Wellness Partner’s subscription to the Platform is terminated or expires; (ii) five (5) years from the date of my signature below; or (iii) my earlier revocation of this Authorization in accordance with the revocation procedure described above.

 

Scope of Access: Platform-Only Disclosure

 

The following conditions apply to all access authorized under this Authorization form:

(a) No Downloads or Copies. My Wellness Partner is not authorized to download, print, copy, screen-capture, photograph, or otherwise extract, reproduce, or retain any of my protected health information, except for my lab results, outside of the Platform.

(b) No Offline Storage or Transmission. My Wellness Partner is not authorized to store, retain, or transmit my protected health information in any system, device, or medium outside of the Platform, including but not limited to email systems, electronic health records, CRM platforms, or personal devices.

(c) Session-Based Access Only. Access to my protected health information is permitted only during active, authenticated sessions on the Platform. My Wellness Partner’s ability to view my protected health information terminates automatically upon logout or session expiration.

(d) Technical Enforcement. Lyv Health implements technical controls within the Platform designed to restrict access to the conditions described above. The existence of such technical controls does not, however, limit or substitute for my Wellness Partner’s independent legal and contractual obligations to comply with this Authorization and all applicable law.

 

Because this Authorization is limited to view-only access through the Platform for my Wellness Partner, my Wellness Partner does not receive a transferable copy of my protected health information, which substantially reduces the risk of unauthorized re-disclosure. Nonetheless, I understand that health information disclosed under this Authorization could be subject to re-disclosure, and that such re-disclosure may no longer be protected by federal and state law, unless prohibited by more restrictive applicable law.

 

By signing up, I affirm that I am at least 18 years of age.

In order to provide lab services, we, Lyv Health Inc., collaborate with Adept Labs, Inc. d/b/a Junction (“Junction”). This agreement allows us to receive your lab testing data for care coordination.

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HIPAA Authorization

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Adept Labs, Inc. d/b/a Junction (“Junction”) provides API solutions for at-home health care. Junction contracts with enterprise customers to grant access to Junction’s services to the customers’ patients like you. As part of its service, Junction works with health care providers and lab testing facilities to facilitate sharing your protected health information as governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 1320d and 45 C.F.R. § 160–164.

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This HIPAA Authorization is to authorize the disclosure of your information from Junction (which provides the lab testing) to Lyv Health, Inc.

 

By signing up for the services, you agree as follows:

  • Pursuant to HIPAA, I authorize and direct Junction to give, disclose, and release, without restriction, my medical records, lab order, and/or lab testing results to Lyv.

  • The purpose of the uses and disclosures is for care coordination.

  • I understand that, with certain exceptions, I have the right to revoke this Authorization at any time. If I want to revoke this Authorization, I must do so in writing. I may revoke this Authorization by sending an email to support@tryJunction.io stating my desire to revoke my HIPAA Authorization. I understand that it may take Junction a few business days to process my revocation.

  • I understand that I may refuse to sign this Authorization, but that will prevent me from participating in Junction’s services. I also understand that my health care provider cannot deny or refuse to provide treatment, payment, enrollment in a health plan, or eligibility of benefits if I refuse to sign this Authorization.

  • I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by applicable federal medical privacy law and could be re-disclosed by the person or agency that receives it.

  • The authority above shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The authority given has no expiration date and shall expire only in the event that the enterprise contract between Junction and Junction Customer terminates or I revoke the authority in writing as specified above.

 

I understand that I have a right to a copy of this Authorization.

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