​

Disclosure Agreement

​

PATIENT AUTHORIZATION AND RELEASE

 

I hereby authorize any health plan, physician, health care professional, hospital, clinic, pharmacy or other health care provider to disclose my personal health information relating to my medical condition, treatment (including prescription information), care management and health insurance, as well as all information provided through this Volunteer Docs Mobile Application to Volunteer Docs Inc., its affiliates and their representatives, agents and contractors (collectively, “Volunteer Docs”) for purposes of managing the Volunteer Docs Mobile Application and providing related services (including but not limited to, investigating insurance coverage; obtaining payment; fulfilling and coordinating delivery; assisting with product training, and providing product support); any internal business use by Volunteer Docs, and to comply with the law. Volunteer Docs may also de-identify my information and share the de-identified information with others for any purpose. I understand that once disclosed to Volunteer Docs, my information may no longer be protected by federal privacy laws and may be re-disclosed by Volunteer Docs; however, Volunteer Docs has agreed that it will not disclose my information except for the purposes stated in this authorization and as otherwise set forth in the Volunteer Docs Terms and Conditions of Use and Privacy Policy, both of which are incorporate herein by this reference. I understand that I may refuse to agree to this authorization, and my refusal will not affect the commencement, continuation or quality of my treatment by my health care provider(s) or my enrollment or eligibility for health benefits. This authorization expires five (5) years after the date of my acceptance, unless I revoke it earlier by sending written notice of revocation to Volunteer Docs Inc., PO Box 48206, Jacksonville, FL 32247. I understand that any revocation will not affect any actions taken by my health care provider(s) or health plan(s) based on this authorization before they receive notice of my revocation.  I understand I may receive a copy of this authorization once signed. I confirm that my name and insurance information provided is correct.

 

I hereby further acknowledge and agree that I shall not pursue legal or other recourse with respect to the recommendations given to me by physicians and other healthcare and medical professionals volunteering their services to Volunteer Docs.  I understand that all such recommendations are on a volunteer and good intent, unbiased basis of the physician’s medical knowledge of my conditions and do not replace the advice or treatment that is currently being offered by my local primary care physicians.

​