HIPAA Marketing Authorization
HIPAA Marketing Authorization (“Authorization”)
I am authorizing my pharmacy and Nimble Rx, Inc. (“NimbleRx”) to use anddisclose my health information, including information related to my medicalcondition, treatment, insurance coverage, my prescriptions and my contactinformation (collectively, “My Information”) for the following purposes:
- To provide me with important health information related to my condition and provide disease management support;
- To send me information about offers and services that may be of interest to me; and
- To evaluate the effectiveness of communications received by me.
My Information may be shared with and used by NimbleRx’s affiliates, agents, and trusted partners for any of the purposes described above. These partners are required by law and contract to protect your information and may only use it for the purposes described in this Authorization.
I understand that:
- I may revoke this authorization at any time. To effectively revoke this Authorization, I must do so in writing and send it
-
- By email to: support@nimblerx.com; or
- By mail to: NimbleRx, Attn: Privacy Officer, 2317 Broadway, Suite 150, Redwood City, CA 94063
- This revocation should include my name, mobile phone number, and my pharmacy name.
- My revocation will not affect actions taken by NimbleRx before receiving my written revocation.
- This authorization is voluntary, and I may refuse to sign this authorization. My receipt of treatment or eligibility for health benefits will not be conditioned on whether I agree to this Authorization.
- I am aware that my pharmacy and Nimble may receive payment or other remuneration from third parties in exchange for obtaining this Authorization and/or making the communications to me that are described in this Authorization.
- I understand that if My Information disclosed pursuant to this Authorization, it may be subject to re-disclosure by the recipient and no longer protected by applicable privacy laws.
- I understand that My Information may include information about my mental health, alcohol or drug abuse, family planning and pregnancy, communicable diseases (like HIV/AIDS), genetic testing and information, and developmental disabilities.
- This authorization will expire three years from the date it was signed or the maximum period permitted under state law, unless I revoke this Authorization at an earlier date.
- I can obtain a copy of this Authorization on my “Account” page in the NimbleRx mobile application.
I am agreeing to this Authorization on my behalf or as the authorized personal representative of the person covered by this Authorization.
HIPAA Marketing Authorization (“Authorization”)
I am authorizing my pharmacy and Nimble Rx, Inc. (“NimbleRx”) to use anddisclose my health information, including information related to my medicalcondition, treatment, insurance coverage, my prescriptions and my contactinformation (collectively, “My Information”) for the following purposes:
- To provide me with important health information related to my condition and provide disease management support;
- To send me information about offers and services that may be of interest to me; and
- To evaluate the effectiveness of communications received by me.
My Information may be shared with and used by NimbleRx’s affiliates, agents, and trusted partners for any of the purposes described above. These partners are required by law and contract to protect your information and may only use it for the purposes described in this Authorization.
I understand that:
- I may revoke this authorization at any time. To effectively revoke this Authorization, I must do so in writing and send it
-
- By email to: support@nimblerx.com; or
- By mail to: NimbleRx, Attn: Privacy Officer, 2317 Broadway, Suite 150, Redwood City, CA 94063
- This revocation should include my name, mobile phone number, and my pharmacy name.
- My revocation will not affect actions taken by NimbleRx before receiving my written revocation.
- This authorization is voluntary, and I may refuse to sign this authorization. My receipt of treatment or eligibility for health benefits will not be conditioned on whether I agree to this Authorization.
- I am aware that my pharmacy and Nimble may receive payment or other remuneration from third parties in exchange for obtaining this Authorization and/or making the communications to me that are described in this Authorization.
- I understand that if My Information disclosed pursuant to this Authorization, it may be subject to re-disclosure by the recipient and no longer protected by applicable privacy laws.
- I understand that My Information may include information about my mental health, alcohol or drug abuse, family planning and pregnancy, communicable diseases (like HIV/AIDS), genetic testing and information, and developmental disabilities.
- This authorization will expire three years from the date it was signed or the maximum period permitted under state law, unless I revoke this Authorization at an earlier date.
- I can obtain a copy of this Authorization on my “Account” page in the NimbleRx mobile application.
I am agreeing to this Authorization on my behalf or as the authorized personal representative of the person covered by this Authorization.
