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 all health care providers (“Health Advisors”) and testing laboratories (“Testing Labs”)
that provide services to me in connection with my subscription to services provided by CompositionID-Houston, LLC (“CompositionID”) to use and/or disclose the protected health information described below to CompositionID-Houston as follows.

2. Authorization for Release of Information. I hereby authorize the release of my complete health record contained in my account with CompositionID-Houston (including without limitation all Health Advisor notes and diagnoses and Testing Labs results and the information I have contributed to my health record contained within my account), covering all past, present and future periods.

3. This health information may be used by CompositionID-Houston in order to provide the CompositionID-Houston 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 subscription to services provided by CompositionID-Houston.

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 Info@CompositionID-Houston.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, my Health Advisors and Testing Labs will no longer be able to disclose my health information to CompositionID-Houston, and that the CompositionID-Houston services 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 my Health Advisors and Testing Labs from disclosing my health information to CompositionID-Houston, and that the CompositionID-Houston 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.

I understand I have the right to receive a copy of this authorization by sending a written request to Info@CompositionID-Houston.com