I hereby authorize any personal and/or medical information collected by myHealthTrack to be disclosed and transmitted to my medical team according to this medical release.

I understand that my personal and/or medical information could be re-disclosed and no longer protected by federal health information privacy regulations if the recipient(s) described on this form are not required by law to protect the privacy of the information.

I hereby acknowledge that any personal and/or medical information related to alcohol or substance abuse, genetic testing, mental health, and/or confidential HIV/AIDS related information that is entered into the myHealthTrack app is my choice and mine alone. If I choose to enter that information, I understand that this authorization gives myHealthTrack the right to disclose that information with my medical team.

I understand that by authorizing the use or disclosure of HIV/AIDS-related information, the recipient(s) is/are prohibited from using or re-disclosing any HIV/AIDS-related information without my authorization, unless permitted to do so under federal or state law. I also understand that I have the right to request a list of people who may receive or use my HIV/AIDS-related information without authorization.

I understand that I have the right to refuse this authorization and that my access to the myHealthTrack app will not be affected if I do not sign this form. I also understand that if I refuse to sign this form, myHealthTrack cannot honor my request to disclose my personal and/or medical information. By not authorizing the disclosure of your personal and/or medical information with your medical team, you may continue using the myHealthTrack app, however, your medical team will have no visibility into your activity or progress.

I understand that I have the right to understand what information covered by this authorization is being shared with my medical team; all of which can be found listed in the Privacy Policy.

I understand that at any time I have the right to revoke authorization of the disclosure of my medical information, except to the extent that myHealthTrack has already taken action based on my initial authorization. But any request to revoke will stop any future disclosures or transmissions of personal and/or medical information.

To revoke this authorization, please contact support@myhealthtrack.com.