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.