Patient Data Upload Authorization

HIPAA AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

This agreement is made between HealthWare LLC and [Patient Name] (hereinafter "Patient").

1. Authorization to Upload and Disclose PHI
By using this service, I, [Patient Name], voluntarily upload my personal health information, including medical records and other sensitive data (collectively, "Protected Health Information" or "PHI"). I understand that this information will be used for medical consultation and treatment planning. I acknowledge that this data will be stored on a secure, HIPAA-compliant server. I understand that I retain the ability to delete this data from this upload server at any time, even after it has been transferred to the clinical EMR/EHR system. If I do not manually delete the data, I acknowledge it will be retained on this server for a maximum of two (2) years before automatic deletion. I understand that deleting files from this upload server does not remove copies that have already been transferred to my permanent medical record in the clinical EMR/EHR system, which is subject to separate medical retention laws. I explicitly authorize the staff of HealthWare LLC (technology provider) and Oakhaven Health (medical provider) to access, view, and transfer this PHI to the clinical medical record system.

2. Electronic Transactions
I, [Patient Name], agree to conduct this transaction electronically. I understand that my checking the box below constitutes my legal signature and acknowledgment that I have read and understood this agreement.

3. Security and Privacy
I understand that security measures are implemented to protect my data in compliance with HIPAA standards. However, I acknowledge that I am responsible for ensuring the security of my own device and internet connection during this upload.

4. Verification
I certify that the email address [Patient Email] is my primary method of contact and I am authorized to use it.