AUTHORIZATION FOR USE AND/OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
Voluntary Participation: You acknowledge that you are voluntarily participating in the healthio program and that in doing so that you will be providing to healthio your biometric and/or longitudinal health data (e.g. body weight, blood pressure, oxygen level, pulse rate, etc.)(your “Protected Health Information” or “PHI”). The healthio program is being offered to you through (i) your employer and/or its health plan, or some other association to which you belong (“Sponsor”), or (ii) a community hub care coordination service organization (“HUB”), and healthio is working with and on behalf of that Sponsor or HUB.
Authorization for Use/Disclosure of Information: By signing into the healthio app, continuing to use the healthio app and/or participating in the healthio program, you voluntarily consent to and authorize healthio Inc. (“healthio,” "our", “we” or “us”) to use and/or disclose your PHI during the term of this Authorization for purposes of and to the recipients described below.
Purposes and Recipients of PHI: By signing into the healthio app, continuing to use the healthio app and/or participating in the healthio program, you authorize us to use and/or disclosure of your PHI for (i) self-administered biometric monitoring, (ii) treatment and monitoring by self-selected individuals or entities, (iii) administration by your Sponsor, (iv) scientific analysis to improve the healthio services or programs, (v) payment by your Sponsor, (vi) healthcare operations, and (vii) legal compliance, and (viii) treatment and monitoring by or through a HUB (if applicable).
Self-Administered Biometric Monitoring: We may use and/or disclose your PHI in connection with the healthio app and self-monitoring of your own PHI.
Treatment and Monitoring by Self-Selected Individuals or Entities: We may use and/or disclose your PHI to those individuals or entities that you have identified as your healthcare advocates, which may include, but may not be limited to, a physician, nurse, pharmacist or other healthcare provider or administrator providing treatment to you, or a family member or close friend or neighbor.
Administration by Your Sponsor: We may use and/or disclose your de-identified PHI (this is your data without any information that links the data to you or identifies you) to allow your Sponsor to administer the healthIO program. If you wish, however, you can choose to invite your Sponsor as a healthcare advocate. If you do so, your identifiable PHI will be shared with your Sponsor. You can make this choice in the healthIO app. If you do not choose to invite your Sponsor, your identifiable PHI will be held in strict confidence.
Analysis to Improve the healthio Services or Programs: We may use and/or disclose your PHI to improve our healthio services or programs.
Payment by your Sponsor or HUB: We may use and/or disclose your PHI necessary to obtain payment from your Sponsorfor services we provide to you.
Healthcare Operations: We may use and/or disclose your PHI in connection with our healthcare operations. Healthcare operations include, but are not limited to, assessing quality and improvement initiatives and activities, creating and conducting training programs, and applying for accreditation, certification, licensing or credentialing activities.
Legal Compliance: We may use and/or disclose your PHI as may be required by any applicable state or federal law or regulation, or as may be ordered by a court of competent jurisdiction.
The following use and/or disclosure is applicable only if you receive treatment from an onsite clinic or other healthcare provide subsidized by your Sponsor:
Treatment and Monitoring by or through an Onsite Clinic: We may use and/or disclose your PHI to those individuals or entities that provide treatment to you through an onsite clinic or other healthcare provided that is subsidized by your Sponsor, which may include, but may not be limited to, a physician, nurse, pharmacist or other healthcare provider or administrator providing treatment to you. Your identifiable PHI will be held in strict confidencewill not be shared with your Sponsor, unless you choose to invite your Sponsor as a healthcare advocate as discussed above.
The following use and/or disclosure is applicable only if you receive community hub care coordination services:
Treatment and Monitoring by or through a HUB: We may use and/or disclose your PHI to those individuals or entities that are involved, directly or indirectly, in your care coordination, which may include, but may not be limited to, a care coordinator, physician, nurse, pharmacist, community hub organization, government agency or other administrator providing or funding care coordination services to you, and/or any individual or entity working on behalf of those listed above.
Term: By signing into the healthio app, continuing to use the healthio app and/or participating in the healthio program, you understand and agree that this Authorization will remain in effect from the date you initially sign into the healthio app until you, your Sponsor, or the HUB cancels your involvement in the healthio program, or you revoke this Authorization pursuant to your rights described below.
Redisclosure: By signing into the healthio app, continuing to use the healthio app and/or participating in the healthio program, you understand that we cannot guarantee that the recipients of your PHI will not redisclose your PHI to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and/or disclosure of your PHI.
Right to Revoke: You understand that agreeing to this Authorization is voluntary. You do not have to agree to this Authorization or participate in the healthio program; however, if you do not agree to this Authorization, you will not be able to participate in the healthio program. Your refusal to agree to this Authorization will not affect your treatment, payment, enrollment or eligibility of benefits provided by or through your Sponsor or the HUB. If you change your mind, you understand that you can revoke this Authorization by providing a written notice of revocation to healthio at the address listed below. The revocation will be effective immediately upon healthio’s receipt and processing of your written notice, except that the revocation will not have any effect on any action taken by healthio in reliance on this Authorization before it received and processing your written notice of revocation. You also understand that by revoking your Authorization that you will no longer be able to participate in the healthio program.
Copy of Authorization: To print a copy of our current Authorization, please visit our website located at http://www.healthio.care/docs/HIPAA-Authorization(copy and paste into your internet browser) and download a PDF copy. If you would like a copy of the Authorization specifically signed by you, please make a request in writing to 12605 W. North Avenue, Suite #228, Brookfield, WI 53005. Please include your name, address, phone number and associated Sponsor or HUB. We may contact you to verify your identity. There may be a minimal fee associated with fulfilling your request (see 45 CFR 164.524(c)(4)).
Questions: You may contact healthio for answers to your questions about the privacy of your Protected Health Information at 12605 W. North Avenue, Suite #228, Brookfield, WI 53005.
Updates and Changes: We reserve the right to amend the terms of this Authorization to reflect changes in our privacy practices. You understand and agree that the new terms and practices, including any updated terms to this Authorization, will apply to all of your PHI, including PHI created, received, used or disclosed prior to the effective date of the updated revision. You agree that it is your responsibility to check back periodically and review any updates to this Authorization, the current form displayed at and paste into your internet browser).