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HIPAA Authorization for Using and Disclosing Protected Health Information
Authorization of Uses and Disclosures.
I hereby authorize and direct Tandem Diabetes Care, Inc., its employees and its agents, including its distributors, product development partners, and trainers (“Tandem and/or its Agents”) to use and disclose my “protected health information” (“Information”), as described below. I also authorize Tandem and/or its Agents to contact me via telephone, mail, e-mail (including unencrypted e-mail), or by other means of communications.
Description of Information.
I understand that my Information includes, but is not limited to, my name and other personal information (including my address), information from the Tandem Patient Information Form, medical information, including information about diabetes and related medical conditions, medical records, and financial information (including information about my insurance) as well as other personal information collected by Tandem about me, such as information on the Health and Product Questionnaire.
I authorize and direct Tandem to use and disclose my Information for the following purposes: (a) reviewing Information about me, and using and disclosing that information to coordinate or arrange delivery of diabetes-related supplies, services or training, including those not yet furnished to me by Tandem and/or its Agents; (b) providing product updates, including regulatory notices relating to existing or future products; and (c) providing information that promotes medical products and/or services that may be of interest to me.
This Authorization expires the later of when I no longer am a patient of Tandem, or ten years after the date of this authorization.
I understand that I have the right to revoke this Authorization by sending a written request to Tandem Diabetes Care, ATTN: Customer Support, 11075 Roselle Street, San Diego, CA 92121, however, I understand that such revocation will not be effective with respect to Information that has already been used and/or disclosed per this Authorization.
Treatment not Conditioned.
I understand that Tandem will not deny service to me based on whether or not I sign this Authorization.
Potential for Redisclosure.
I understand that Information disclosed pursuant to this Authorization may be redisclosed by recipients (including me) and may no longer be protected by the Health Insurance Portability and Accountability Act (“HIPAA”), a federal privacy law.
I understand that I will be provided with a copy of this signed Authorization by Tandem.