Authorization for Use and Disclosure of Protected Health Information
This Authorization is required under the HIPAA Privacy Rule (45 C.F.R. § 164.508) when TIDL Health Inc or its Providers use or disclose your Protected Health Information ("PHI") for purposes that are not already permitted without authorization (such as treatment, payment, or healthcare operations). You do not need to sign this form to receive treatment from TIDL Health Inc. Signing is voluntary.
1Purpose of this Authorization
If you want a friend, spouse, family member, caregiver, employer, attorney, or any other person or entity to be able to receive information about your care from TIDL Health Inc, you must designate them through this Authorization. Complete the Authorization in your patient account, or send a written request to privacy@tidl.com.
2Patient information we will confirm
When you complete this Authorization, we confirm your full legal name, date of birth, and email on file before any disclosure is made.
3Persons or entities authorized to receive PHI
You authorize TIDL Health Inc, its Providers, and its Business Associates to disclose your PHI to the person(s) or entity(ies) you name, including each person's relationship to you and a phone number or email for contact.
4Specific information authorized for disclosure
You may authorize release of any of the following categories:
- Demographic information (name, date of birth, contact info)
- Appointment scheduling, status, and reminders
- Billing, payment, and account status information
- Clinical progress, diagnoses, and treatment plans
- Prescriptions and medication information
- Laboratory results
- Complete medical record on file with TIDL Health Inc
- Other information you describe in writing
Disclosure of the following sensitive categories requires specific, separate authorization under federal and/or state law, and is made only if you specifically authorize it:
- Mental or behavioral health information
- Substance use disorder records (42 C.F.R. Part 2)
- HIV/AIDS status or testing
- Genetic testing information
- Sexually transmitted infection information
- Reproductive health information
5Purpose of disclosure
You will choose a purpose when you sign, which may be:
- At your request, for personal reasons (no further explanation required)
- To coordinate care with another healthcare provider
- For legal or insurance purposes
- Another purpose you describe in writing
6Expiration
This Authorization will expire on the earliest of:
- The date you revoke it in writing;
- One (1) year from the date of signature; or
- A specific date or event you name when you sign.
7Right to revoke
You have the right to revoke this Authorization at any time by submitting a written revocation to TIDL Health Inc at privacy@tidl.com or through the Platform's patient portal. Revocation will be effective upon receipt, except to the extent that TIDL Health Inc has already relied on this Authorization before receiving the revocation.
8Redisclosure warning
Once your PHI is disclosed to the person(s) or entity(ies) you identify, it may no longer be protected by HIPAA and may be subject to redisclosure by the recipient.
9Conditions of treatment
TIDL Health Inc will not condition your treatment, payment, enrollment, or eligibility for benefits on whether you sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).
10Copy
You are entitled to a copy of any Authorization you sign.
This page is the public text of the Authorization. Designating recipients and capturing a signature happens in your patient account or by written request. Do not send PHI to this website.