AUTHORIZATION FOR RECEIPT, USE, AND/OR DISCLOSURE OF HEALTH INFORMATION

Completion or acceptance of this document authorizes the receipt, use, and/or disclosure of your health information as set forth below, consistent with Federal and state law concerning the privacy of such information. Failure to provide all information requested may invalidate this Authorization.

USE AND DISCLOSURE OF HEALTH INFORMATION

1. I hereby authorize the receipt, use, and disclosure of my health information by Simplee solely in accordance with the Simplee Privacy Policy.
2. I also hereby authorize Simplee to transmit for maintenance and storage to its subcontracted hosting service company, Amazon Web Services, my encrypted health information, with the encrypted health information encrypted and otherwise secured so that it is unreadable and otherwise unaccessable by Amazon Web Services or other third parties or persons.
3. I understand that the purpose of Simplee’s use and disclosure of my health information is solely to provide me with the services described in the Simplee Terms of Service.
4. This Authorization applies to all my health and billing information on the websites for which I provide Simplee with my username and password and pertaining to any medical history, mental or physical condition and treatment received (including mental health records protected by state law, genetic test results, drug and/or alcohol abuse records and/or HIV test results) other than psychotherapy notes.

EXPIRATION

This Authorization expires January 1, 2050.

RESTRICTIONS

California law prohibits the recipient of my health information from making further disclosure of my health information unless the recipient obtains another authorization from me or unless such disclosure is required or permitted by law. The disclosure of my health information from Simplee to AWS is expressly permitted by this Authorization under the conditions set forth herein.

YOUR RIGHTS

I may refuse to sign this Authorization and neither treatment, payment, enrollment or eligibility for benefits will be conditioned on my providing or refusing to provide this Authorization. I understand that if I do not sign or accept this form, neither Simplee nor AWS will receive, use, or disclose my medical information.

I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to Simplee at the address specified in Simplee’s Privacy Policy. My revocation will be effective upon receipt, but will not be effective to the extent that Simplee or others have acted in reliance upon this Authorization.

I have a right to receive a copy of this Authorization. I may inspect or obtain a copy of the health information received, used, or disclosed subject to this Authorization.

If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may be redisclosed and may no longer be protected.