Symliphy Care

HIPAA Acknowledgement and Authorization

Acknowledgement and Authorization for Use and Disclosure of Protected Health Information to GenieMD Medical Group, MO, P.C. and Affiliates

This is an Authorization for Use and Disclosure of Protected Health Information (the "Authorization") in compliance with federal privacy laws, including the Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Economic and Clinical Health Act (collectively, "HIPAA").

Please read this entire form before signing. Electronic signatures, including clicking "I agree" as part of using DC4ME's telehealth service platform, suffice. Entities that arrange the provision of health care services for people, such as DigitalCareForMe, LLC d/b/a Symliphy, an Ohio limited liability company ("DC4ME"), must obtain a signed authorization from the individual or the individual's legally-authorized representative to electronically disclose or otherwise transmit that individual's protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this authorization form will not affect payment, enrollment, or eligibility for benefits.

I. Acknowledgement and Authorization for the Use or Disclosure of PHI

I authorize DC4ME and its affiliates, contractors, and employees to disclose certain Protected Health Information that I or my dependent provide through DC4ME's mobile app and/or website that pertains to me or my dependent ("PHI") to GenieMD Medical Group, MO, P.C., a Missouri professional corporation, and its affiliates (collectively, "GenieMD") for the purposes of providing health care and/or prescription services as indicated in or necessitated by any health symptom questionnaire(s) I complete on behalf of myself, or based on any information I provide to DC4ME.

A non-exclusive list of PHI that may be disclosed by DC4ME to GenieMD includes, but is not limited to:

1. Contact Information (for example, email address);
2. Demographic Information (for example, date of birth);
3. Symptom information, including questionnaire answers and any health-related information provided independently or in conjunction with any questionnaire;
4. Account Information (for example, DC4ME account profile); and
5. My complete patient file, including medical history and all information related thereto.

II. Important Information About Your Rights

1. This Authorization is voluntary. Refusing to sign this Authorization will not prevent me from obtaining health care services from any healthcare provider that provides asynchronous and/or live telehealth services through DC4ME's health services vehicles by reaching out to the healthcare provider directly.
2. I may revoke this Authorization at any time by sending a written revocation notice to DC4ME and may use DC4ME's form to do so. The revocation will not have any effect on any disclosure that any healthcare provider took in reliance on this Authorization before receiving my revocation notice.
3. Information disclosed pursuant to this Authorization may be re-disclosed by the recipient, and this redisclosure will no longer be protected by HIPAA.
   Click here to Download HIPAA Revocation Form
4. I have a right to a copy of this authorization.
5. This Authorization expires five years after I cease to receive any services from any healthcare provider provided by DC4ME or any entity with which it contracts.

HIPAA Authorization for Marketing Communications

A separate and voluntary authorization

This authorization is separate from the treatment authorization above and is entirely voluntary. It is not required to receive treatment, and signing or declining it will not affect your treatment, payment, enrollment, or eligibility for benefits.

Authorization

I authorize Symliphy, its affiliated healthcare providers, pharmacies, business associates, and authorized service providers to use and disclose my Protected Health Information ("PHI") to send me marketing communications about healthcare products, services, programs, educational resources, wellness initiatives, promotions, and other offerings that may be of interest to me.

Information That May Be Used

The PHI that may be used or disclosed includes:

1. My name;
2. Mailing address;
3. Email address;
4. Telephone number;
5. Demographic information;
6. Prescription and medication information;
7. Health conditions or treatment categories;
8. Pharmacy or healthcare provider relationship;
9. Appointment history; and
10. Other information reasonably necessary to personalize healthcare communications.

Symliphy will not disclose more information than reasonably necessary to provide these communications.

Types of Communications

I understand that I may receive communications through:

1. Text messages (SMS or RCS);
2. Telephone calls (including prerecorded or AI-assisted calls where permitted by law);
3. Email;
4. Mobile application notifications;
5. Postal mail; and
6. Other electronic communication methods that I authorize.

These communications may include:

1. Medication and prescription-related services;
2. Wellness and preventive care programs;
3. New healthcare services;
4. Health education;
5. Promotions and special offers;
6. Surveys and patient engagement opportunities; and
7. Other healthcare-related information that may benefit me.

Financial Remuneration

Symliphy may receive financial remuneration from third parties for certain marketing communications. I understand that this authorization permits such communications as required by the HIPAA Privacy Rule.

Voluntary Authorization

1. Signing this authorization is voluntary.
2. My decision to sign or not sign will not affect my treatment, payment, enrollment, or eligibility for benefits.
3. I may refuse to sign without impacting the healthcare services I receive.

Right to Revoke

I understand that I may revoke this authorization at any time by submitting a written request to: Privacy Officer, Symliphy, PO Box 561, Mason, OH 45040, Email: dataservices@symliphy.com. My revocation will not affect any use or disclosure Symliphy made before it received my written revocation.

Expiration

This authorization will remain in effect until the earliest of: (a) five (5) years from the date I sign this authorization; (b) the date I revoke this authorization in writing; or (c) any earlier date required by applicable law.

Redisclosure

I understand that information disclosed under this authorization may no longer be protected by HIPAA if it is redisclosed by the recipient, except where otherwise prohibited by law.

Copy of Authorization

I understand that I have the right to receive a copy of this signed authorization.

Patient Acknowledgment

By providing this authorization electronically — including by clicking "I agree" or otherwise opting in — I acknowledge that I have read and understand this authorization and voluntarily authorize the use and disclosure of my Protected Health Information for marketing communications as described above. Where a personal representative provides this authorization on the patient's behalf, the representative confirms their authority to act for the patient and their relationship to the patient.