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OOIDA

Dr. John's Call Center

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HIPAA Policy / Privacy Agreement

Read the following statement. Check and sign below to state that you understand and agree to these terms. A statement of your signature will be e-mailed to you.

1. I authorize any physician, medical practitioner, hospital, clinic or other medical or medically related facility to release or disclose my personal health information (as described below) to the following entities: (1) Sleep Access, LLC; and (2) Sleep Access Network, LLC (hereinafter “Receiving Party”).
2. This authorization is made in accordance with the federal and state law and is valid for a period of twenty (24) months after being signed.
3. I understand that I may revoke this authorization at any time by sending a written revocation to Sleep Access, LLC except to the extent that it has taken action in reliance on the authorization.
4. I understand that once my health information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure or release by the Receiving Party and may no longer be protected by federal or state law.
5. The health information I authorize for use or disclosure is any and all information in my medical record pertaining to sleep disorder disease management services, testing and fatigue prevention.
6. This authorization for release of my health information is provided for the purpose of providing information to the Receiving Party to enable claims processing and documentation of my treatment by a Sleep Access Network LLC affiliated health care provider.
7. I have been provided with a copy of this authorization for my records.

I have read and understand these terms.