In accordance with the U.S. Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164 ("HIPAA"):
1. I hereby authorize Prosocial Applications, Inc. ("Prosocial") to release to the Recipient named above the following protected health information ("PHI") and other personally identifiable information ("PII") contents of my RK360 Records that I selected for transmission to you via my RK360 Mobile App.
2. I hereby authorize the Recipient to use my PHI/PII for the sole purpose(s) of being fully informed about my health history and status in preparation for providing me with healthcare services.
Additional Terms and Conditions
1. Revocation. This Authorization may be revoked at any time upon written request of the Patient
2. Conditions. Prosocial and Recipient will not condition treatment, payment, enrollment or eligibility for benefits on whether the Patient signs this Authorization
3. Re-disclosure. Patient acknowledges that the Recipient may re-disclose Patient's PHI/PII such that it may no longer be protected under HIPPA or other laws applicable to Prosocial and/or the Recipient.
4. Digital Documentation. A copy, fax or email of this authorization will be as valid as the original.
I certify that this request is made voluntarily and that the information given above is accurate to the best of my knowledge.