AUTHORIZATION FOR USE OF MEDICAL INFORMATION
I hereby express my intention and desire, of my own free will, to participate in one or more Health Fairs, Health Expos, or other organized community health Activity and/or health research Activity, including without limitation Free Yourself from the Flu Clinic (“Community Health Activity”). In consideration of my opportunity to participate in such Community Health Activity, I hereby acknowledge and agree to the following:
1. While certain other entities providing services in the Community Health Activity in which I participate are “covered entities” under certain federal and state laws relating to medical record privacy, including the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (“HIPAA”), I acknowledge and recognize that neither Dr. Oz, “The Dr. Oz Show,” ZoCo Productions, LLC, or any other affiliated producer, broadcaster, licensee, or related entity (including OWN: The Oprah Winfrey Network), is a “covered entity” under HIPAA or otherwise obligated as such under any medical record privacy laws or regulations.
2. I recognize and acknowledge that I may be required to sign privacy documents and authorizations with those health care providers and other entities that provide medical or healthcare services in connection with the Community Health Activity, and that I will not be allowed to participate in the Community Health Activity without signing such documents.
3. I hereby authorize The Dr. Oz Show, ZoCo Productions, LLC, and any of their subsidiaries, affiliates and related entities, including without limitation any producers, broadcasters, licensees, or other related entities, to use and/or disclosure any of my “Protected Health Information” (as defined in 45 CFR 164.501) in any form or fashion related to the Community Health Activity, including any release to any third party involved in the Community Health Activity. I further authorize any such third party participating in the Community Health Activity to further use and/or disclose any of my Protected Health Information for any use or purposes related in any way to the Community Health Activity (including any Community Health Activity engaged in by such parties in which I do not directly participate), as well as any entity engaged in clinical, pharmaceutical, dietary, or other medical research. The Protected Health Information for which this authorization is provided can be specifically described as any and all information related to me or my health that is produced or disclosed in connection with the Community Health Activity or may be disclosed by any of my providers or caregivers to any participant in the Community Health Activity. Authorization for the use and/or disclosure of such Protected Health Information is specifically granted for the purposes of aiding in community health, population health management, research, and any other health-related purposes, including without limitation treatment or any other healthcare purposes specifically related to me or my medical condition.
4. My authorization hereunder is subject to the following specific conditions: I agree that the persons and entities authorized above may use and/or disclose my Protected Health Information for the purposes listed above and any related purposes. I recognize that once my Protected Health Information is released, the Protected Health Information may be subject to re-disclosure by the recipient and in such event may not be protected under the privacy rules promulgated under HIPAA. I acknowledge that I have the right to print out and keep a copy of this Authorization, and that I may receive a copy of it at any time upon written request to ZoCo Productions, LLC, 40 Rockefeller Plaza, 43rd Floor, New York, NY 10112, Attention: Legal Department. I recognize that no party may condition treatment, payment, enrollment, or eligibility for benefits (as applicable) on whether I sign this authorization, but that my participation in the Community Health Activity will not be allowed without my authorization hereunder. I acknowledge that I am voluntarily signing this authorization. This authorization will remain effective until December 31, 2050, or until all Community Health Activity, including any continuations, follow-ups, or related research Activity, are concluded, whichever occurs later. I acknowledge that I have the right to revoke this authorization at any time except to the extent that action has already been taken based on this authorization. Any such revocation must be in writing, and submitted to the address set forth above. Once this authorization is revoked, the entities authorized above will not further use or disclose the Protected Health Information for the above-stated purpose; however, I recognize that no revocation will be applicable to the extent that such authorized entity has already relied on the authorization.