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 I have the right to refuse to sign this authorization, but if I do, my physician will not be able to track my progress using the myHealthTrack app and would need to track my progress and provide me with information on rehabilitation through alternate methods.

Information covered by this authorization includes but is not limited to: name, email, phone, date of birth, information you access in the app, exercise activity you perform and/or record using the app, how often you access information in the app, answers to questions the app may pose regarding your recovery, and your insurance carrier. A complete list of information covered by this authorization can be found 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.

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 agree to be notified by email rather than postal mail if there is a breach of the information listed above.

This authorization is effective for 1 year from the date accepted. To revoke this authorization, please contact [email protected].