Authorization for Use and Disclosure of Protected Health Information
By agreeing to this Authorization, you authorize your health care provider to disclose your protected health information (“PHI”) to L-Nutra for purposes of enabling you to utilize the Online Marketplace on your health care provider’s website, and for L-Nutra to otherwise use and disclose your PHI in connection with fulfilling orders for L-Nutra’s products on the Online Marketplace, and for the purpose of providing customer support through L-Nutra and their third party associates. The PHI that may be used and disclosed pursuant to this Authorization includes your name, address, email address, telephone number, and other information that you provide on the Online Marketplace. Information shared will be limited to the minimum amount required for associates to perform their contracted responsibilities.
Additionally, you understand and agree to the following:
- I understand that I do not need to sign this Authorization to receive health care treatment from my health care provider.
- I understand that I may receive a copy of this Authorization by contacting my health care provider.
- I understand that the PHI subject to this Authorization may be protected by law. I understand that such PHI may be re-disclosed by the recipient and no longer protected by the federal health information privacy law known as HIPAA. However, other laws in certain states may prohibit the recipient of my PHI from making further disclosure of my information, unless another authorization is obtained from me or unless the further disclosure is specifically permitted or required by law.
- I understand that I have the right to revoke this Authorization in writing at any time by contacting my health care provider. Revoking this Authorization will not have any effect on actions in reliance on the Authorization before the notice of my revocation was received.
- I understand that this Authorization will terminate one (1) year from the date on which I agree to this Authorization, unless I revoke it sooner.