AUTHORIZATION TO USE AND DISCLOSE (RELEASE) HEALTH INFORMATION

By signing below, I authorize all of the health care providers and laboratories (“Providers”) to use or disclose, release, and submit the health information described below to Kyma for purposes of utilizing the Services provided by Kyma for other lawful purposes. Once the health information is submitted to Kyma, I may be contacted by Kyma.

The health information that I authorize to be disclosed as described above includes:

• All medical records, including contact information, progress notes, nursing notes, consultation reports, procedure notes, operative reports, discharge summaries, patient assessment forms, medication lists, orders, evaluations, substance use disorder treatment records and notes, reproductive health information, imaging test results, and laboratory test results, which results may include genetic testing or screening results used to identify genes, genetic abnormalities, or inherited or acquired characteristics in genetic material.

Acknowledgements. 

I understand and confirm the following:

• I understand and consent that Kyma may obtain information and updates from my Wearables to provide information and updates to my health care provider for care coordination purposes. 

• I understand that recipients of health information disclosed under this Authorization may not be subject to HIPAA and that the health information could be re-disclosed to third parties if permitted by applicable law.

• I do not have to sign this Authorization, and the health care providers may not condition (withhold or refuse) treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization.

• I may change my mind and revoke (take back) this Authorization at any time, except to the extent that a health care provider has already acted based on this Authorization. The revocation will be effective when the Provider authorized to make the disclosure receives the revocation.

• Unless revoked, this Authorization expires seven (7) years from the date it is signed.

• Providers will, where required, include a copy of this authorization and a notation concerning the persons or agencies to whom disclosure was made with my original health records.

• I have a right to receive a copy of this Authorization. 

I have read and understand this Authorization, and my questions have been answered. As the person signing this authorization, I understand that I am giving my permission for the health care providers to disclose confidential health records.