HIPAA Authorization to Release Protected Health Information

At my request, I authorize Vital and BioReference Laboratories to release my health information, including my telehealth visit information and laboratory test results related to all services that I have requested or ordered through the Death Clock platform, to Death Clock.

This authorization will end when I cancel my subscription with Death Clock.

In accordance with applicable state law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards, I understand and agree that:

I have the right to revoke this authorization, in writing, at any time, except where action has been taken based upon my authorization. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. 

It is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards or state law. If I am authorizing the release of alcohol or drug treatment, mental health treatment, psychotherapy notes, or HIV related information, the recipient is prohibited from re­disclosing such information or using the disclosed information for any other purpose without my authorization, unless permitted to do so under federal or state law.

Signing this authorization is voluntary. My treatment by any party, payment, enrollment in a health plan, or eligibility for benefits may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study).

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original. I acknowledge that checking the checkbox next to this HIPAA Authorization in Death Clock’s application constitutes my signature of this form.