ikioo

Provider Authorization

(FULL ACCESS)

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

 

  • Review the following elements of my personal health record as maintained by ikioo (check each that applies):
    • ________________
    • ________________
    • ________________
    • ________________
    • ________________
    • ________________
  • Record recommendations or other information on and/or communicate with me through my personal health record; and
  • [Other? Please describe].

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

 

I also understand that the Provider may submit recommendations and comments onto my ikioo personal health record or directly to me.  I understand that these recommendations are the Provider’s alone and ikioo is not responsible for the accuracy and/or representations made by the Provider. 

 

This authorization shall expire upon (1) my termination of my ikioo account; or (2) my removal of Provider as an authorized user of ikioo.  I may terminate my ikioo Account or terminate a Provider 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 Provider has already acted based on this Authorization.  I may revoke this Authorization by removing Provider 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.