PRIVACY POLICY

HIPAA Privacy

I, on behalf of myself and all dependents, hereby authorize the release of my complete health record from all health care providers, including any licensed physician, medical practitioner, hospital, clinic pharmacy benefits manager or other pharmacy related services provider or other medical or medically related facility provider, insurance company or other organization, institution or person, that has any records or knowledge of me or any dependent, including but not limited to personal information, records concerning physical or mental illness, information relating to autoimmune deficiency syndrome (AIDS), human immunodeficiency virus (HIV), communicable diseases, criminal history as it relates to health care, the use of drugs or alcohol or other advice, diagnosis, prognosis, prescription information, care or treatment provided to me or any dependent, to release such information to Caremax Pharmacy or its authorized representatives

I, on behalf of myself and all dependents, hereby provide Caremax Pharmacy with consent to use my complete health record and personally identifiable information for general treatment, underwriting, payment or health care operations, including but not limited to coordination of care, quality of care assessment, billing or claims payment, utilization review, fraud detection, risk management review or accreditation purposes. I understand information obtained with my authorization may be re-disclosed by Caremax Pharmacy as permitted or required by law and in some instances may no longer qualify for protection under Federal and State privacy laws.

Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state HIPAA or medical privacy regulations. However, other state or federal law may prohibit the recipient from disclosing specially protected information, such as substance abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information. Caremax Pharmacy and its respective employees, officers, health care providers and agents are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for participation in research programs, or authorization of the release of testing results for pre-employment purposes. I understand I may be charged a retrieval/processing fee and for copies of my medical records. I understand my treatment will not be conditioned by my completion of this form. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. If this authorization is not earlier revoked, this authorization shall terminate within one year from today’s date. 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 certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that a photocopy or electronic copy of this authorization shall be considered as effective and valid as the original.