Authorize to Release

Revised as of July 5th, 2023

 

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

I, the undersigned, understand and agree to the following uses and disclosures of my protected health information:

• My personal health information is confidential and will be used and disclosed by Wondr Health as necessary for treatment, payment, health care operations and special situations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include case management.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be submission of a claim for payment for the Wondr Health program.
• Health care operations include the business aspects of running health care business, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review or acting as a business associate of a health plan.
• Special Situations include disclosures for my safety or for the safety of the general public; to individuals involved in my care or payment for my care (unless I specifically object to such disclosures); for instances of national security; for worker’s compensation; for organ donation programs (if I am an organ donor); to military command (if I am a member of the armed services); to coroners, medical examiners or funeral directors; or as otherwise required by law.
• Wondr Health may also create and distribute de-identified health information by removing all references to individually identifiable information.

• I understand my employer will receive de-identified reports to allow evaluation of the program, and participation reports to enable administration of related payroll and billing processes. I understand and agree that my employer and/or my employer’s designee (such as a third-party administrator) may also receive, via hard copy or electronically, a list of program applicants for purposes of verifying eligibility and/or a roster of enrolled program participants, which contain identifiers such as name, employee identification number, date of birth and other demographic and/or contact data. I understand that if my employer’s eligibility criteria for enrollment in the program are based on certain health-related criteria or conditions, the provision of the roster of program participants will identify me as meeting that criteria or having that condition. I authorize Wondr Health to release program participation rosters containing my information to my employer and/or to my employer’s designee.
• If the Wondr Health program has been provided to me by my employer, then my employer recognizes the importance of safeguarding my individually identifiable health information, and all organizations involved in the program are obligated to take reasonable steps to protect such information from unauthorized access or use.
• Except as provided above, I understand the information I provide to Wondr Health is confidential and available only to Wondr Health, its administrators, agents, licensees, and subcontractors involved in conducting or evaluating the program (“Affiliates”), and me.
• My biometric screening results, if applicable, may be released to Wondr Health for purposes of completing the application for enrollment and/or providing de-identified reports to allow evaluation of the program.
• Wondr Health cannot sell or otherwise divulge any employee information to any unauthorized party.

This Authorization is valid until I specifically revoke it in writing. I understand that I can revoke this Authorization at any time by giving written notice of my intent to revoke it. I understand that uses or disclosures taken prior to the revocation will not be affected. I have read this form and agree to the uses and disclosures of the information described. I understand that participation in the Wondr Health program is voluntary. I understand that information disclosed pursuant to the Authorization may be subject to re-disclosure by the recipient and may no longer be subject to federal or state privacy laws.