– Your Authorization to Disclose Your Subscription Information to Service Provider
In subscribing to the My Health Newsletter, My Health Reminders, My Baby Expectations and/or My Health Links, (collectively, the “Service”), and in providing the information in the prior subscription webpage (the “Information”), I hereby authorize the use and disclosure of the Information to both Private Health News, Inc. (“PHN”) and CommonSpirit, the organization operating this website (“Medical Facility”). Medical Facility may use and disclose the Information in accordance with the Patient Privacy Notice. PHN will receive and use the Information to provide the Service. I understand that the Service is without cost to me and that Medical Facility will not receive remuneration from PHN or any third party for the use or disclosure of my Information. This authorization is voluntary and my refusal to provide the Information will not affect my right to receive health care at Medical Facility, but any refusal will affect my ability to receive the Service. I may revoke this authorization at anytime by unsubscribing from the Service. Any such revocation shall not have any effect on disclosures of the Information by Medical Facility to PHN occurring prior to the revocation and will not limit PHNs use of the Information. I understand that the Information I provided could be re-disclosed by PHN and such re-disclosure is in some cases no longer protected by federal confidentiality law (HIPAA) or by state law. I also understand that if I have any questions about this authorization, I may contact the Medical Facility’s Privacy Office identified in the Patient Privacy Notice. Otherwise, all of my questions have been answered to my satisfaction and I fully understand the terms of this authorization form and have had the opportunity to print out a copy if I so desire. This authorization is valid as of today’s date and shall expire when I unsubscribe from the Service.