ASYNCHEALTH HIPAA AUTHORIZATION  

By signing this HIPAA Authorization (the “Authorization”), I authorize and request my “Treatment Organization” to disclose the following limited health information to AsyncHealth, Inc. (“Async”) or for Async to collect such health information and provide it to Treatment Organization: all of my (or my child’s) name, contact information, audio, video, and photographic material taken of me, which shall include all of my health information disclosed during such interviews, which shall specifically include my mental health diagnosis or treatment information, substance abuse treatment information, HIV information, as applicable (together, the “Health Information”).  

If I decide to sign this form, I have the right to request that audio/video recording, filming, or photographing cease at any time.  

Purpose: 

I understand that the purpose of this Authorization is to allow Async to perform the interview services to provide to my Treatment Organization so I can receive care, and to allow Async to use such Health Information, in a de-identified, aggregated format to perform quality improvement, data analytics, machine learning, and algorithmic development to further analyze and develop Async’s products and services. I understand that my contact information will only be used for the purposes of Async, my Treatment Organization, or for payment purposes, and not otherwise disclosed to any other individual or entity. 

Accordingly, by signing this Authorization below, I hereby authorize Async to take and make use of my and/or my Health Information, which may include my sensitive mental health information, substance abuse treatment information, and/or HIV information for the Purpose described above.  

Acknowledgements: 

I understand that once my Health Information has been de-identified, in accordance with the Health Information Portability and Accountability Act of 1996 (“HIPAA”) requirements, it is no longer protected by HIPAA or subject to this authorization. 

I further understand that if the person or entity that receives my Health Information is not required to comply with applicable privacy regulations, then the Health Information described above may be re-disclosed by the recipient and is no longer protected by the HIPAA privacy rule. 

I understand that I do not have to grant this Authorization. I am accepting this Authorization voluntarily and I understand I am not restricted from receiving services from my Treatment Organization should I decide not to sign this Authorization. I further understand that my eligibility for benefits under my insurance plan may not be conditioned upon my acceptance of this Authorization. 

I hereby forever discharge, hold harmless and release Async from all claims, demands and causes of action which, I, my heirs, representatives, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this Authorization. I hereby release and forever discharge Async from any and all claims and demands arising ort of or in connection with the use of the Health Information in the development of any Asnyc products or services.  

Expiration 

I understand that this Authorization is in effect until I revoke it. 

Revocation Rights 

I further understand that I have the right to revoke this Authorization, in writing, at any time by sending notice to [INSERT ASYNC CONTACT EMAIL]. I acknowledge and understand that the revocation will be effective immediately upon the Async’s receipt of my written notice; however, the revocation will not affect any uses or disclosures of the Health Information that were already made by Async prior to receipt of the written notice of revocation.  

DICLAIMER LANGUAGE TO BE INSERTED INTO PRODUCT  TO BE SEEN BY PATIENT BEFORE THEY START THE INTERVIEW 

ASYNCHEALTH, INC. IS NOT A PROVIDER OF CLINICAL CARE OR ADVICE. ASYNCHEALTH, INC. IS NOT PROVIDING YOU WITH ANY TREATMENT OR DIRECTLY RESPONSIBLE FOR YOUR CARE.  THE PRECORDED INTERVIEWER REPRESENTED BY ASYNCHEALTH, INC. IS NOT A CLINICIAN, IS NOT PROVIDING YOU WITH ANY TREATMENT, AND IS NOT DIRECTLY INVOLVED OR RESPONSIBLE IN YOUR CARE. BEFORE YOU TAKE ANY ACTION THAT MAY AFFECT YOUR HEALTH OR SAFETY, OR THE HEALTH OR SAFETY OF OTHERS, PLEASE CONSULT WITH A MEDICAL PROFESSIONAL.  IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY, CALL YOUR LOCAL EMERGENCY PHONE NUMBER OR YOUR HEALTH CARE PROVIDER IMMEDIATELY.  IF YOU ARE THINKING ABOUT SUICIDE, OR IF YOU ARE CONSIDERING TAKING ACTIONS THAT MAY CAUSE HARM TO YOU OR TO OTHERS, OR IF YOU FEEL THAT YOU OR ANY OTHER PERSON MAY BE IN ANY DANGER, OR IF YOU HAVE ANY MEDICAL EMERGENCIES, CALL 911 IMMEDIATELY AND NOTIFY ANY RELEVANT AUTHORITIES.  THE SUICIDE HOTLINE IS 988 OR 800-273-8255 IF FACED WITH AN IMMEDIATE OR EMERGENT CRISIS.  THERE ALSO MAY BE OTHER NATIONAL, REGIONAL, AND STATE RESOURCES AVAILABLE TO YOU.