I, the Client, hereby authorize the use or disclosure of my protected health information as described below:
1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Måna Care AB is authorized to disclose the following Personal Health Information (PHI) to all identified and selected Trusted Advisors of the Client through the Måna Dashboard App.
2. DESCRIPTION OF INFORMATION TO BE DISCLOSED
The personal health information that may be disclosed consists of:
Electronic Health Information containing SpO2, Herat Rate, Temperature, Blood Pressure, ECG/EKG, and Blood Glucose
All past, present, and future periods of health care information may be shared.
3. PURPOSE OF THE USE OR DISCLOSURE
The purpose of this use or disclosure is to enable designated Family Advisors, Caregivers, Medical Technicians, and Doctors the ability to determine the health condition of the client and recommend any additional follow up testing or course of action.
4. VALIDITY OF AUTHORIZATION FORM
This Authorization Form is valid at the time of the recorded acknowledgement during checkout or invoice is issued. The agreement of these terms will be recorded during the checkout process on the Måna Care AB website or by receiving an invoice. This authorization will expire when the client cancels their subscription or returns their Måna platform to Måna Care AB.
5. ACKNOWLEDGMENT
I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.
I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
By checking the box at checkout , the client is agreeing to the terms of this contract and signed on behalf of the Client by their identified Trusted Advisor who may be a Caregiver, Family member, or Friend acting on behalf of the Client.