Previvor Edge HIPAA Authorization for the Release of Protected Health Information

By registering for the Previvor Edge Program (the “Program”), you have already authorized Previvor Care Inc. (“Previvor”) to collect and use certain identifiable health information in connection with the care and services provided by the clinicians and healthcare providers as part of the Program.  This HIPAA authorization is agreed to in connection with your participation in the Program and will permit Previvor to retain and use this information in accordance with this authorization.  

Accordingly, you hereby authorize the release of the following protected health information:

• Personally identifying health and medical information (including payment and insurance information where applicable) collected by Previvor in connection with your participation in the Program and/or collected or generated by Previvor or the third party clinicians and healthcare providers involved in the Program;
• Medical information included in your medical record that is collected in connection with and/or created in the performance of your diagnosis and treatment in the Program, which may include genetic testing information, and
• Any additional information provided by you to Previvor or by your healthcare providers to Previvor in connection with your participation in the Program.

This medical information may be used by Previvor to manage your participation in the Program, including in communications with other parties who are authorized by you.  Previvor may also use this information for research and other Program-related purposes that will support Previvor’s business, including with Previvor’s affiliates and partners, in strict compliance with Previvor’s Privacy Policy and all applicable laws and regulations. Previvor may receive remuneration for use of this information. You understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

You understand that you have the right to revoke this authorization, in writing, at any time, by notifying Previvor at support@previvoredge.com. You understand that a revocation is not effective to the extent that Previvor or any person or entity has already acted in reliance on your authorization or if your information has been de-identified and cannot be re-identified. Unless you request in writing to revoke your authorization, you understand that this authorization will be effective until 10 years after closure of the Program.

You agree that you are authorized to sign this document and to authorize the release and uses of the protected health information contained herein.  You understand that your treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether you sign this authorization. Upon your acceptance and signature, a copy of this authorization will be maintained by Previvor and will be provided to you upon your request. 

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