Arivale Member Permission Form to Share My Health Information with my Physician

This Member Permission Form states you give your permission to have Arivale licensed health professionals disclose and discuss your lab and genetic results and overall health results in your Arivale program participation with your physician. The purpose of having our clinical staff discuss your results with your physician is to better assist you in your Arivale program and to be sure your physician has the most complete information about your health and wellness. Arivale will not discuss any other aspect of your participation in our program with your physician without your express written permission. You agree that Arivale’s communication with your physician may occur by telephone or secure email.

  • This form is not required to participate in the Arivale program. We do not need to speak with your physician for you to participate in Arivale or for you to receive any of the standard elements included in the program.
  • This form is voluntary and you may revoke it at any time by notifying Arivale in writing of your desire to revoke it (email concierge@arivale.com). However, any action already taken in reliance on this authorization cannot be reversed, and your revocation will not affect those actions.
  • This authorization is valid for two years from the date signed, or until you revoke it in writing, whichever comes first.
  • There is potential that information disclosed under this Authorization may be disclosed by the recipient and may no longer be protected by federal HIPAA regulations.
  • This authorization is at the request of the individual (you).

I hereby authorize Arivale to disclose protected health information about me to my physician.

 

If you have any questions about this form, please contact the Arivale Concierge at 206-567-7273.

*The HIPAA Privacy Rule requires Arivale to follow certain procedures before it may provide access to your Protected Health Information (PHI) to someone other than you. PHI is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health condition, and the provision of health care to you or the payments for that care. Arivale provides a separate HIPAA authorization during your initial program member sign-up.