Authorization To Disclose Health Information

Last updated: February 9, 2020
1.
I authorize all of the persons and entities listed below to provide any and all medical or health-related information about me (my “Health Information”) to Aktibo, Inc. d/b/a Sproutt (“Sproutt”) for the purpose of assisting me with obtaining life insurance benefits:
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Any health system, hospital, clinic, pharmacy, or other health care or medical facility;
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Any physician, nurse, medical practitioner, or other licensed medical professional;
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Any laboratories and other entities that arrange for or provide medical exams or laboratory tests on behalf of an insurance carrier or such carrier’s agent or other authorized representative;
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Any health plan or third-party administrator of a health plan;
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Any pharmacy benefit manager or pharmacy-related service organization;
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Any health care clearinghouse;
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Any insurance or reinsurance carrier (including, but not limited to, carriers of disability, life, accident, and automobile medical insurance coverage);
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Any entity subject to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its implementing regulations;
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Any entity subject to the federal Confidentiality of Substance Use Disorder Regulations at 42 C.F.R. Part 2.
2.
I understand that Sproutt will use and share the Health Information it receives from the persons and entities listed in Section 1 above to: (a) evaluate my needs for life insurance benefits and match me with appropriate insurance carriers; (b) assist me with applying for, and obtaining, life insurance benefits from an insurance carrier; and (c) determine my eligibility for life insurance policies offered by insurance carriers. I acknowledge that Sproutt may share my Health Information with the following types of third parties:
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Insurance carriers and policy underwriters;
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Health care providers; laboratories; and other entities that arrange for and provide medical exams and laboratory tests on behalf of the insurance carriers and policy underwriters;
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Other third parties as needed to support the matching and application process, issuance of a life insurance policy, and the policy underwriting process.
3.
I understand that Health Information refers to the following types of information about me:
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Medical records; medical reports and notes; and other information about the testing, diagnosis, and prognosis of any physical or mental health condition;
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Pharmaceutical records, medication history, and other information related to prescription drugs;
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Laboratory records, diagnostic test results, and pathology reports;
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Insurance claims history and other information about payment for health care services;
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Any “individually identifiable health information” as defined by HIPAA.
4.
I also understand that Health Information may include certain, highly sensitive information about me (“Sensitive Health Information”), if any such information exists. I specifically request and authorize the persons and entities listed in Section 1 above to provide my Sensitive Health Information from the following categories to Sproutt:
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Information related to the testing or diagnosis of, or treatment for, communicable, venereal, or sexually transmitted disease (including, but not limited to, HIV/AIDS, hepatitis, syphilis, gonorrhea, chlamydia, or herpes);
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Genetic test results or information;
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Mammography test results;
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Substance use disorder information, including information related to the diagnosis of, or treatment for, alcohol or drug abuse disorder;
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Information about mental health, mental illness, or developmental disabilities;
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Confidential communications with a psychotherapist, psychologist, social worker, sexual assault counselor, domestic violence counselor or other mental health professional or human services professional, including psychotherapy notes;
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Information about developmental disabilities;
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Information about family planning or abortion services;
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Information about sexual assault, child abuse and neglect, or abuse of an adult with a disability.
5.
This authorization will be valid for two (2) years from the date I sign it, unless I revoke this authorization on an earlier date.
6.
My provision of this information is voluntary. However, I understand that if I do not provide this authorization, Sproutt’s ability to assist me with obtaining life insurance benefits may be limited.
7.
I understand that I may revoke this authorization in writing by contacting Sproutt at privacy@sproutt.com. I understand that I may also revoke this authorization in writing by contacting the health care provider, health plan, or other person or entity listed in Section 1 above that shared my Health Information with Sproutt. I acknowledge that my revocation will not apply to any information that has already been released pursuant to this authorization.
8.
I understand that a health care provider, health plan, or health care clearinghouse that is subject to HIPAA (“HIPAA Covered Entity”) may not condition treatment, payment, health plan benefits enrollment, or eligibility for health plan benefits on whether or not I sign this authorization. Notwithstanding, if the HIPAA Covered Entity is providing me with health care solely for the purpose of gathering Health Information to share with Sproutt, then the HIPAA Covered Entity may condition its provision of health care on my signing of this authorization.
9.
I understand that once a person or entity listed in Section 1 above discloses my Health Information to Sproutt, there is no guarantee that Sproutt will not re-disclose the Health Information to a third party. Further, the third party may not be required to comply with this authorization, HIPAA, or other applicable law governing the use and disclosure of my Health Information. However, if my Health Information includes substance use disorder program records or information that is protected by the federal Confidentiality of Substance Use Disorder Regulations at 42 C.F.R. Part 2, the information cannot be re-disclosed by the third party without my specific written consent.
10.
I understand that I may print a copy of this authorization form or request a copy of this authorization form by contacting Sproutt at hello@sproutt.com.
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