Patient HIPAA Authorization and Notice of Release of Information

VibrantConnect Program — MedOptions RX & Vibrant Gastro

I hereby authorize the use and disclosure of my personal and protected health information, such as my name, address, medical records, prescription and insurance information, with or by the following parties:

  • MedOptions RX LLC and its subsidiaries and affiliates, contractors, employees, agents and successors (collectively, “MedOptions RX”);
  • Vibrant Gastro, Inc. and its subsidiaries and affiliates, contractors, employees, agents and successors (collectively, “Vibrant Gastro”); and
  • “The VibrantConnect Program” which supports and effectuates continuity of care, claims processing and payment, provider and insurer communication, reimbursement procedures, and program administration.

MedOptions RX, Vibrant Gastro, and the VibrantConnect Program Entities are individually and collectively referred to as the “Companies”.

I authorize the Companies to use and disclose my personal and protected health information as follows:

  • among the Companies;
  • to or from my physician or representatives of my physician or other health care providers involved in my care;
  • to or from health insurers.

The purpose of any of the above-stated use or disclosure of my protected health information is to carry out treatment, payment and healthcare operations, including assisting in continuity of treatment; claims settlement; submission of claims to health insurers for payment; communication of information to my physician, other health care providers, and insurance carriers; reimbursement of services; and administration of the VibrantConnect Program.

I also authorize and understand that the Companies and other health care providers involved in my care may use and disclose my protected health information for quality assurance purposes, including but not limited to quality assurance reviews. In addition, and without limiting the above-stated use and disclosure, I authorize the Companies to use or disclose my personal information and protected health information for the following purposes:

  • To enroll me in the VibrantConnect Program;
  • To provide me with information about the Vibrant System;
  • To provide me with other educational information related to my medical condition;
  • To assist me in obtaining payment for the Vibrant System or other medications; and
  • To refer me to, and/or enroll me in, additional support services and/or related support programs, as applicable.
I hereby authorize the Companies to contact me by mail, e-mail, text, or telephone. I also authorize MedOptions RX to send health-related information (PHI) to me via encrypted SMS, and acknowledge the security risks.

I understand that MedOptions RX will receive financial remuneration from pharmaceutical manufacturers, such as Vibrant Gastro, to provide some of these communications to me and that the use and disclosure of my information as described in this Authorization may be considered use or disclosure for “marketing” under the Health Insurance Portability and Accountability Act (HIPAA). I authorize these uses and disclosures to the extent they are directly related to the VibrantConnect Program, my prescription, services associated with my prescription, or other specialty pharmacy or support programs.

I understand that I am not required to sign this Authorization as a condition to receive treatment with Vibrant Gastro’s products, MedOptions RX’s services, payment for health care services, enrolling in a health plan, or establishing eligibility for benefits. I also understand that by refusing to sign this Authorization, I will not be able to enroll in the VibrantConnect Program.

I understand that this Authorization shall remain in effect until it expires, unless I revoke it sooner. I may revoke this Authorization at any time by notifying MedOptions RX in writing at the following address:

450 E Devon Ave, Suite 170 Itasca, IL 60143 Attn: VibrantConnect Program Leader Email: vibrantconnect@medoptionsrx.com

I understand that the revocation will be effective upon actual receipt of my written revocation by MedOptions RX at the above street or email address. If I revoke this Authorization, I understand that the revocation of this Authorization will not affect the use or disclosure of my name or other portions of my protected health information described above, by MedOptions RX or the Companies, prior to the date of revocation, but that after the date of revocation, neither my name nor any other protected health information pertaining to me will be used or disclosed based on this Authorization.

I understand that the protected health information released based on this Authorization may be subject to redisclosure by the recipient and no longer be protected under HIPAA and its related privacy regulations.

I understand that I may refuse to agree to this Authorization. If I agree to this Authorization, I will be given a copy of this Authorization.

This Authorization expires ten (10) years from the date this Authorization is agreed to or signed unless revoked before that time.

My electronic acknowledgment or signature of this Authorization certifies that I have read and understood this Authorization and authorize the use and disclosure of my protected health information as described above and I have been provided with and agree to the terms set forth in the MedOptions RX’s Notice of Privacy Practices.