The Relief Institute’s primary goal is providing a valuable service to you the patient by helping you to locate, learn about, and engage with certified healthcare providers in your area that are best suited to address your medical condition. As part of this process we need to procure, manage, and forward your service request forms, health history forms, and other health-related information to share with the Healthcare Provider you have chosen to expedite your care. The service requests, health history forms or other health-related information can be provided by you through the data collection form on the website or other media, information taken from our customer care team, as well as, history forms provided by the Healthcare providers for use in conjunction with the services provided by Relief Institute. As part of the services provided by Relief Institute, Relief Institute may collect, use, share, and exchange your health history forms and other health-related information with Your Healthcare Providers. Under a federal law called the Health Insurance Portability and Accountability Act (“HIPAA”), health and health-related information may be considered “protected health information” or “PHI” if such information is received from or on behalf of Your Healthcare Providers.
HIPAA protects the privacy and security of your PHI by limiting the uses and disclosures of PHI by most healthcare providers and by health plans (called “Covered Entities”) as well as companies, like Relief Institute, that provide certain types of assistance to Covered Entities (called “Business Associates”). Under certain circumstances described in HIPAA, an individual needs to sign an Authorization form before a Covered Entity, like your Healthcare Provider(s), can disclose protected health information to a third party.
Non-Protected Health Information
The purpose of your PHI Authorization (“Authorization”) is to request your written permission to allow Relief Institute to use and disclose your PHI in the same way as we use and disclose your Non-PHI. If Relief Institute is a Business Associate of Your Healthcare Provider(s), Relief Institute needs your Authorization to be able to use and disclose your PHI in the same way it can currently use and disclose your Non-PHI when Relief Institute is not working on behalf of Your Healthcare Provider(s), but is instead working on its own behalf. Therefore, when Relief Institute relies on this Authorization, and uses and discloses PHI as described in this Authorization, it is not working as a Business Associate and the HIPAA requirements that apply to Business Associates will not apply to such uses and disclosures.
If you engage and complete the information form on Relief Institute website or other provided media and/or verbally with Relief Institute care team, then you give your permission to Relief Institute to retain your PHI and to use and/or disclose your PHI in the same way that you have agreed that your Non-PHI can be used and disclosed.
Specifically, you agree that Relief Institute can use your PHI to:
enable and customize your use of the Services provided by Relief Institute;
provide you alerts or other Relief Institute Services regarding additional Healthcare Provider Options;
notify you regarding providers we think you may be interested in learning more about;
share information with you regarding services, products or resources about which we think you may be interested in learning more;
provide you with updates and information about the Services provided by Relief Institute;
conduct analysis for Relief Institute’s business purposes;
support development of the Services offered by Relief Institute; and
create de-identified information and then use and disclose this information in any way permitted by law, including to third parties in connection with their commercial and marketing efforts.
You also agree that Relief Institute can disclose your PHI to:
third parties assisting Relief Institute with any of the uses described above;
Your Healthcare Provider(s) to enable them to refer you to, and make appointments directly themselves, or other providers on your behalf, or to perform an analysis on potential health issues or treatments, provided that you choose to use the applicable services offered by Relief Institute;
a third party as part of a potential merger, sale or acquisition of Relief Institute;
our business partners who assist us by performing core services (such as hosting, billing, fulfillment, or data storage and security) related to the operation or provision of our services, even when Relief Institute is no longer working on behalf of Your Healthcare Provider(s);
a provider of medical services, in the event of an emergency; and
organizations that collect, aggregate and organize your information so they can make it more easily accessible to your providers.
If Relief Institute discloses your PHI, Relief Institute will require that the person or entity receiving your PHI agrees to only use and disclose your PHI to carry out its specific business obligations to Relief Institute or for the permitted purpose of the disclosure (as described above) Relief Institute cannot, however, guarantee that any such person or entity to which Relief Institute discloses your PHI or other information will not re-disclose it in ways that you or we did not intend or permit.
Expiration and Revocation of Authorization
Your Authorization remains in effect until you provide written notice of revocation to Relief Institute.
YOU CAN CHANGE YOUR MIND AND REVOKE THIS AUTHORIZATION AT ANY TIME AND FOR ANY (OR NO) REASON.
If you wish to revoke this Authorization, you must notify Relief Institute by submitting a revocation directly to Relief Institute. Your decision not to execute this Authorization or to revoke it at any time will not affect your ability to use certain Services provided by Relief Institute. A Revocation of Authorization is effective after you submit it to Relief Institute, but it does not have any effect on Relief Institute’s prior actions taken in reliance on the Authorization before revoked.
Once Relief Institute receives your Revocation of Authorization, Relief Institute can only use and disclose your PHI as permitted in Relief Institute’s agreements with Your Healthcare Provider(s). Your Revocation of Authorization does not affect Relief Institute’s use of your Non-PHI.
We will make available to Your Healthcare Provider(s), current and past, your agreement to or revocation of this Authorization.