Patient Data Treatment Authorization

Patient Data Treatment Authorization

RECITALS

WHEREAS, Patient Name: , Patient ID: , DOB: (collectively "Patient") seeks clinical services and related handling of personal and health information.

WHEREAS, Provider Name: , Provider Contact: (collectively "Provider") is authorized to deliver clinical services and to create, collect, use and disclose patient data necessary for treatment, payment and healthcare operations as further described below.

WHEREAS, the parties desire to set forth the scope, duration, and conditions under which Patient authorizes Provider to treat and process Patient data, and to establish payment and confidentiality obligations.

SCOPE OF WORK

Types of data to be created, accessed, or processed (check all that apply):

Medical records and clinical notes
Diagnostic imaging and lab results
Genetic and genomic data
Billing and insurance information
Other (specify):

AUTHORIZATION FOR SHARING

Patient expressly authorizes Provider to disclose the specified data to the following third parties for the stated purposes:

Consent for research or marketing use (optional):
I consent to de-identified use of my data for research
I consent to use of my contact information for provider communications (marketing)

PAYMENT TERMS

Unless otherwise agreed in writing, Patient remains responsible for amounts not covered by insurer. Provider may suspend non-urgent data processing services for unpaid balances subject to written notice.

TERM AND TERMINATION

Effective Date: . Termination Date:

Either party may terminate this Authorization for any reason by delivering written notice to the other party in accordance with the notice period above. Termination does not affect rights to process data collected prior to termination where retention is required by law or necessary for medical continuity; such retained data remains subject to the confidentiality obligations herein for the retention period specified.

CONFIDENTIALITY

Provider shall implement and maintain reasonable administrative, technical and physical safeguards to protect Patient data against unauthorized access, disclosure, alteration and destruction. Provider will limit access to Patient data to personnel with a legitimate need to know and will ensure such personnel are bound by confidentiality obligations no less protective than those in this Authorization.

Provider may disclose Patient data to the extent required by law, subpoena or court order, provided Provider gives Patient notice of such demand when permitted to do so and limits the disclosure to the minimum required.

In the event of an unauthorized disclosure or security breach affecting Patient data, Provider will notify Patient without unreasonable delay and will cooperate in mitigation and remedial measures.

GOVERNING LAW

This Authorization and any dispute arising out of or relating to it shall be governed by the laws of the state of , without regard to conflict-of-law principles.

LIMITATION OF LIABILITY & INDEMNIFICATION

Except for willful misconduct or gross negligence, Provider's liability for damages arising from performance under this Authorization is limited to direct damages and shall not exceed the total amounts paid by Patient to Provider under this Authorization during the twelve (12) months preceding the event giving rise to the claim. Each party shall indemnify and hold harmless the other from third-party claims arising from the indemnifying party's breach of its obligations hereunder.

ENTIRE AGREEMENT

This Authorization constitutes the entire agreement between Patient and Provider with respect to the matters addressed herein and supersedes all prior and contemporaneous agreements, representations and understandings, whether written or oral, relating to such matters. Any amendment or modification must be in writing and signed by both parties.

REVOCATION AND ACKNOWLEDGMENT

Patient understands that this Authorization is voluntary and may be revoked at any time by providing written notice to Provider, subject to Provider's reliance on disclosures made before receipt of revocation and to any legal obligations to retain records. Patient acknowledges receipt of a copy of this Authorization and affirms that they have had the opportunity to ask questions and receive answers about the uses and disclosures described herein.

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