By accepting where indicated below, I hereby authorize [insert Name, relationship, and email address] (hereinafter, “Provider”) to have access to my ikioo personal health record. By authorizing Provider to have access to my ikioo account, I acknowledge and agree that I am authorizing Provider to:
- Review the following elements of my personal health record as maintained by ikioo (check each that applies):
- Notes
- Labs
- Diagnositics
- Medications
- Providers
- Vision Profile
- Dental History
- Pharmacy
- Insurance
- Insurance Coverage
|
- Medical Facility
- Records
- Advanced Directives
- Code Status
- Past Surgical History
- Past Medical Hisotry
- Family Hisotry
- Travel History
- Social History
|
- Genetics Profile
- Allergy History
- Immunization History
- Menstrual History
- Next of Kin
|
- Record recommendations or other information on and/or communicate with me through my personal health record; and
- [Other? Please describe].
I understand that that once my information is disclosed to Provider, I will no longer have control over my health information and Provider may re-disclose my health information in such manner as Provider may determine from time to time. ikioo will not be responsible for re-disclosures by Provider.
I also understand that the Provider may submit recommendations and comments onto my ikioo personal health record or directly to me. I understand that these recommendations are the Provider’s alone and ikioo is not responsible for the accuracy and/or representations made by the Provider.
This authorization shall expire upon (1) my termination of my ikioo account; or (2) my removal of Provider as an authorized user of ikioo. I may terminate my ikioo Account or terminate a Provider by following the directions on my ikioo account at any time. In addition, I can request assistance from ikioo in so doing by sending an email to [add address].
By signing where indicated below, I acknowledge that:
I may revoke this Authorization at any time. Such revocation will promptly take effect except to the extent that my Provider has already acted based on this Authorization. I may revoke this Authorization by removing Provider as an authorized user of my ikioo account.
Signed on [Insert Date Automatically]
Fill in the following information:
Last Name, First Name and MI: ______________________
Date of Birth: [DD/MM/YYYY] ____________________
Relationship to subject of information: [Place “x” in the appropriate box below]
[ ] Self
[ ] Parent/Guardian/Other Legal Representative
By clicking [I ACCEPT], I acknowledge and agree to the terms of this authorization.