LAST UPDATED: MAY 15, 2017
Authorization to Use or Disclose (Release) Personal Health Information
By signing this authorization, I hereby authorize my health plans, physicians, and pharmacy providers (collectively, my "Providers") to use and/or disclose my personal health information ("PHI") to Obalon Therapeutics Inc. and its affiliates to use or disclose (release) my PHI for the purposes of facilitating my treatment with the Obalon Balloon System. My authorization applies to any PHI governed and protected by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as amended, and under the rules and regulations thereunder. For example, PHI that Obalon and it affiliates may use or disclose (release) for purposes of this authorization may include:
- Phone Number
- Appointment Date
- Treatment Date
Should I choose to seek treatment with an Obalon affiliate, that affiliate is required by law to protect my PHI. By signing this authorization, I authorize all Obalon affiliates to use and/or disclose (release) my PHI for the purpose of facilitating your treatment with Obalon. I understand that my PHI used or disclosed under this authorization may be re-disclosed by the person(s) or class of person(s) receiving it and may no longer be protected Federal privacy laws (such as the Privacy Rule). I understand that my health care providers and insurance company will not condition my medical treatment, payment of treatment, insurance enrollment, or eligibility for insurance benefits on my signing this authorization. I understand that I am entitled to a copy of this authorization. I understand that I may cancel this authorization at any time by mailing a letter requesting such cancellation to email@example.com, but that this cancellation will not apply to any information already used or disclosed. The PHI used or disclosed pursuant to this authorization may be re-disclosed as described above. This authorization expires one (1) year from the date signed below. I further understand that I am entitled to a copy of this authorization.
If this authorization is being signed by the patient’s legal representative, you must provide legal documentation authorizing you to act on the patient’s behalf (legal guardianship, power of attorney, personal representative).
If this authorization is being signed on behalf of a minor child, we may require additional information before this request is considered complete.