Common use of HIPAA AUTHORIZATION Clause in Contracts

HIPAA AUTHORIZATION. I give permission to Right Dose to use or disclose certain aspects of my health information to the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the that I received as being either a capped rental or an inexpensive or routinely purchased item. I have been given the opportunity to and did examine the Medicare Capped rental and inexpensive or routinely purchased items notification and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy to use or disclose certain aspects of my health information to to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. I have read and understand the above terms and conditions and agree to be bound by each of them: Signature [Resident or Responsible Party]: Date: NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy’s privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the certify that I have received as being either a capped rental or an inexpensive or routinely purchased item. I copy of ▇▇▇▇▇▇’▇ Extended Care Pharmacy’s Injury, infection, and emergency preparedness protocol and have been given the an opportunity to and did examine review the Medicare Capped rental and inexpensive or routinely purchased items notification document and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Guardian Pharmacy of Michigan to use or disclose certain aspects of my health information to to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. I have read and understand the above terms and conditions and agree to be bound by each of them: Signature [Resident or Responsible Party]: Date: NOTICE OF PRIVACY PRACTICES [▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Guardian Pharmacy of Michigan’s privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Guardian Pharmacy of Michigan is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Guardian Pharmacy of Michigan’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the certify that I have received as being either a capped rental or an inexpensive or routinely purchased item. I copy of Guardian Pharmacy of Michigan’s Injury, infection, and emergency preparedness protocol and have been given the an opportunity to and did examine review the Medicare Capped rental and inexpensive or routinely purchased items notification document and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Guardian Pharmacy of Michigan to use or disclose certain aspects of my health information to to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. I have read and understand the above terms and conditions and agree to be bound by each of them: Signature [Resident or Responsible Party]: Date: NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Guardian Pharmacy of Michigan’s privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Guardian Pharmacy of Michigan is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Guardian Pharmacy of Michigan’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the that I received as being either a capped rental or an inexpensive or routinely purchased item. I have been given the opportunity to and did examine the Medicare Capped rental and inexpensive or routinely purchased items notification and was given an opportunity to ask questions to assist my understanding of it. I certify that I have received a copy of Guardian Pharmacy of Michigan’s Injury, infection, and emergency preparedness protocol and have been given an opportunity to and did review the document and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Guardian Pharmacy of Dallas/Fort Worth to use or disclose certain aspects of my health information to to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. I have read and understand the above terms and conditions and agree to be bound by each of them: Signature [Resident or Responsible Party]: Date: NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Guardian Pharmacy of Dallas/Fort Worth’s privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Guardian Pharmacy of Dallas/Fort Worth is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Guardian Pharmacy of Dallas/Fort Worth’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the certify that I have received as being either a capped rental or an inexpensive or routinely purchased item. I copy of Guardian Pharmacy of Dallas/Fort Worth’s Injury, infection, and emergency preparedness protocol and have been given the an opportunity to and did examine review the Medicare Capped rental and inexpensive or routinely purchased items notification document and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy to use or disclose certain aspects of my health information to the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose ▇▇▇▇▇▇’▇ Extended Care Pharmacy Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the that I received as being either a capped rental or an inexpensive or routinely purchased item. I have been given the opportunity to and did examine the Medicare Capped rental and inexpensive or routinely purchased items notification and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Ron’s Pharmacy to use or disclose certain aspects of my health information to to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Ron’s Pharmacy’s privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Ron’s Pharmacy is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Ron’s Pharmacy’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the certify that I have received as being either a capped rental or an inexpensive or routinely purchased item. I copy of Ron’s Pharmacy’s Injury, infection, and emergency preparedness protocol and have been given the an opportunity to and did examine review the Medicare Capped rental and inexpensive or routinely purchased items notification document and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose ▇▇▇’s Pharmacy to use or disclose certain aspects of my health information to to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose ▇▇▇’s Pharmacy’s privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose ▇▇▇’s Pharmacy is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose ▇▇▇’s Pharmacy’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the certify that I have received as being either a capped rental or an inexpensive or routinely purchased item. I copy of ▇▇▇’s Pharmacy’s Injury, infection, and emergency preparedness protocol and have been given the an opportunity to and did examine review the Medicare Capped rental and inexpensive or routinely purchased items notification document and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Guardian Pharmacy of South Georgia to use or disclose certain aspects of my health information to to: the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Guardian Pharmacy of South Georgia’s privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Guardian Pharmacy of South Georgia is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Guardian Pharmacy of South Georgia’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the that I received as being either a capped rental or an inexpensive or routinely purchased item. I have been given the opportunity to and did examine the Medicare Capped rental and inexpensive or routinely purchased items notification and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Guardian Pharmacy of Daytona to use or disclose certain aspects of my health information to the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Guardian Pharmacy of Daytona privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Guardian Pharmacy of Daytona is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Guardian Pharmacy of Daytona’s Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the that I received as being either a capped rental or an inexpensive or routinely purchased item. I have been given the opportunity to and did examine the Medicare Capped rental and inexpensive or routinely purchased items notification and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Guardian Pharmacy of Orlando to use or disclose certain aspects of my health information to the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Guardian Pharmacy of Orlando privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Guardian Pharmacy of Orlando is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Guardian Pharmacy of Orlando Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the that I received as being either a capped rental or an inexpensive or routinely purchased item. I have been given the opportunity to and did examine the Medicare Capped rental and inexpensive or routinely purchased items notification and was given an opportunity to ask questions to assist my understanding of it.

HIPAA AUTHORIZATION. I give permission to Right Dose Guardian Pharmacy Gulf Coast to use or disclose certain aspects of my health information to the individual listed as my personal representative, my long-term care facility, federal and state health agencies, insurance companies, third-party data aggregators, pharmacy benefit managers, and other health-related agencies. NOTICE OF PRIVACY PRACTICES [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I have received a copy of Right Dose Guardian Pharmacy Gulf Coast privacy practices and have been given an opportunity to review the document and ask questions to assist my understanding of resident’s rights relative to the protection of resident’s health information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/]. I further acknowledge that I am satisfied with the explanations provided to me and am confident that Right Dose Guardian Pharmacy Gulf Coast is committed to protecting my health information. I certify that I have read and understand this agreement: I certify that I have received a copy of Right Dose Guardian Pharmacy Gulf Coast Notice of Non-Discrimination and Complaint Procedures and have been given an opportunity to and did review the document including the free disabilities aids and language services available and was given an opportunity to ask questions to assist my understanding of it. I am confident I understand my rights and my options if I believe I have been discriminated against or guardian has failed to provide certain services. I received instructions and understand that Medicare defines the that I received as being either a capped rental or an inexpensive or routinely purchased item. I have been given the opportunity to and did examine the Medicare Capped rental and inexpensive or routinely purchased items notification and was given an opportunity to ask questions to assist my understanding of it.