Common use of HIPAA AUTHORIZATION Clause in Contracts

HIPAA AUTHORIZATION. I give permission to Guardian Pharmacy of St. Louis 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. 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 Guardian Pharmacy of St. Louis’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 Guardian Pharmacy of St. Louis 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 Guardian Pharmacy of St. Louis’s payment information and understand the available ways to pay my bills 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 Guardian Pharmacy of St. Louis Missouri 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. 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 Guardian Pharmacy of St. LouisMissouri’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 Guardian Pharmacy of St. Louis Missouri 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 Guardian Pharmacy of St. LouisMissouri’s payment information and understand the available ways to pay my bills 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 Guardian Preferred Care Pharmacy of St. Louis 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. I have read and understand the above terms and conditions and agree to be bound by each of them: Signature [Resident Signature[Resident or Responsible Party]: Date: NOTICE OF PRIVACY PRACTICES [PRACTICES[▇▇▇▇://://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa-privacy-policy/] I certify that I thatI have received a copy of Guardian Pharmacy of St. LouisPreferred Care Pharmacy’s privacy practices and have been given an opportunity to review the document and ask questions to assist my questionstoassistmy understanding of resident’s rights relative to the protection of resident’s health rightsrelativetotheprotectionof resident’shealth information. I know that I can access the Notice of Privacy Practices on the Guardian Pharmacy website at [▇▇▇▇://http://▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇/hipaa- /hipaa-privacy-policy/]. I policy/].I further acknowledge that I am satisfied with the explanations provided to me and am confident that Guardian Preferred Care Pharmacy of St. Louis 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 Guardian Pharmacy of St. Louis’s payment information and understand the available ways to pay my bills 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.: