HIPAA Privacy and Release of Information Authorization
I hereby authorize TIERO and its affiliates, its employees, and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, claims payment, and health care services provided or to be provided to me and which identifies my name, address, date of birth or any other information that I provide to Tiero) for the purpose of helping to resolve claims and health benefit coverage issues. I understand that any personal health information or other information released to the person or organization identified may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws. I understand that I have a right to revoke this authorization by providing written notice to Tiero. However, this authorization may not be revoked if it’s employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization which is available on Tiero.com. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I further understand that this authorization is voluntary. By agreeing to this HIPAA Privacy and Release of Information Authorization I represent that I am the legal person who is authorizing Tiero to obtain COVID-19 home test kits and that I am legally authorized to act with respect to this authorization form for myself or any other person for whom I order Covid-19 home test kits, including any minor.