Authorization for Release of Personal Data
In connection with my request for medical support services, including consultation, second opinions, care management, navigation, and related services (collectively, “Services”), You voluntarily authorize the use or disclosure of my personal and health data (“Data”) as described below. You understand that: • Refusing to provide this authorization may affect my ability to receive the requested Services. • This authorization is voluntary, but the ability of Nick Global Medical Group, PC, and its affiliated professionals to provide Services depends on their ability to review my Data. • Once disclosed, your Data may no longer be protected by applicable data privacy laws.
• Providers of the Data: • Online/ Website / platform / ExpertView / Nick health Inc users • Recipients of the Data: • Nick Global Medical Group, PC, and its affiliated professionals • Nick Health Inc. (administrative services provider) • Assigned Case Navigator (to be determined by the organizations listed above)
This authorization applies to all personal and health data that you voluntarily provide, including but not limited to: • Data provided online through Nick Global Medical Group’s website or third-party platforms • Data shared via email, chat, regular mail, telephone, or through my Case Navigator • Medical history, treatment details, and any supporting documentation related to the Services I request You understand that the specific information provided will depend on the Services you request.
The information will be used for the following purposes: 1. To deliver the requested Services. 2. To provide administrative support by Nick Health Inc. and my assigned Case Navigator. Important: Nick Global Medical Group, PC, and its affiliates will not sell, share, or disclose the provided health information for financial or in-kind compensation.
Mavis Clinic is open Monday through Friday from 8:00 AM to 6:00 PM. Additionally, we offer limited hours on Saturdays from 9:00 AM to 12:00 PM to accommodate our patient’s diverse schedules. Please note that our clinic is closed on Sundays and major holidays.
By checking the box, You acknowledge the following: 1. Revocation Rights: You understand that You may revoke this authorization at any time by providing written notice. However, revocation will not apply to any actions taken before the notice is received. 2. Potential Redisclosure Risks: You acknowledge that once disclosed, my Data may be subject to redisclosure by the recipients, and it may no longer be protected by applicable data privacy laws. 3. Expiration of Authorization: This authorization will expire either: • Upon completion of all requested Services, or • One (1) year after the date of consent, whichever comes later. 4. Access to Information: You understand that You may request to review and copy the information described in this form and receive a copy of the signed consent. ( signed mean check the check box )
By checking the box via webstie form, You confirm that you have read, understood, and agreed to the terms outlined above. You agreed and consent to the Authorization for Release of Personal Data.