ikioo

Authorized Individual Authorization

(READ ONLY ACCESS)

By accepting where indicated below, I hereby authorize [insert Name, relationship, and email address] (hereinafter, “Authorized Individual”) to have read-only access to my ikioo personal health record.  By authorizing Authorized Individual to have read-only access to my ikioo account, I acknowledge and agree that I am authorizing Authorized Individual to:

  • Review the following elements of my personal health record as maintained by ikioo (check each that applies):
    • ________________
    • ________________
    • ________________
    • ________________
    • ________________
    • ________________
  • [Other? Please describe].

My Authorized individual will not be able to contact me or my Provider(s) through ikioo personal health record.

I understand that that once my information is disclosed to Authorized Individual, I will no longer have control over my health information and Authorized Individual may re-disclose my health information in such manner as Authorized Individual may determine from time to time.  ikioo will not be responsible for re-disclosures by Authorized Individual. 

This authorization shall expire upon (1) my termination of my ikioo account; or (2) my removal of Authorized Individual as an authorized user of ikioo.  I may terminate my ikioo Account or terminate an Authorized Individual by following the directions on my ikioo account at any time.  In addition, I can request assistance from ikioo in so doing by sending an email to [add address].

 

By signing where indicated below, I acknowledge that: 

 

I may revoke this Authorization at any time.  Such revocation will promptly take effect except to the extent that my Authorized Individual has already acted based on this Authorization.  I may revoke this Authorization by removing Authorized Individual as an authorized user of my ikioo account. 

 

Signed on [Insert Date Automatically]

 

Fill in the following information:

 

Last Name, First Name and MI:  ______________________

 

Date of Birth:  [DD/MM/YYYY] ____________________

 

Relationship to subject of information: [Place “x” in the appropriate box below]

[  ]  Self

[  ]  Parent/Guardian/Other Legal Representative

By clicking [I ACCEPT], I acknowledge and agree to the terms of this authorization.




ikioo

Authorized Individual Acceptance

You, [Authorized Individual], are being granted access to the online medical information of another person.  By clicking the Accept button, you are verifying that you have the right to access this information, granted to you by [ikioo Customer Name].  If you feel that you've received this access in error, please contact ikioo.com.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

By accepting where indicated below, I acknowledge and agree that [Name of ikioo customer] (hereafter “Customer”) has authorized me [Name of Authorized Individual] (hereinafter, “me” or “Authorized Individual”) to have full access to Customer’s ikioo personal health record.  By authorizing me to have full access to Customer’s ikioo account, I acknowledge and agree that I may:

  • Review the following elements of my personal health record as maintained by ikioo (check each that applies):
    • ________________
    • ________________
    • ________________
    • ________________
    • ________________
    • ________________
  • [Other? Please describe].

I further acknowledge that this authorization shall expire upon (1) Customer’s termination of his or her ikioo account; or (2) Customer’s removal of me as an authorized user of Customer’s ikioo account. 

As an Authorized Individual user of ikioo.com, by accepting where indicated below I acknowledge and agree that I have read and agreed to ikioo’s terms of use and privacy policy. 

I further acknowledge and agree that I will use and disclose the information maintained by Customer on ikioo.com in the best interest of Customer.

 

Signed on [Insert Date Automatically]

Fill in the following information:

Name of Authorized Individual:  ___________________________________

Authorized Individual for [Name of Customer]:  _______________________