Terms and Conditions
UROLOGY CENTERS OF ALABAMA (UCA) BOOK APPOINTMENT AND PATIENT COMMUNICATION AUTHORIZATION
Please Review Carefully
UCA offers Appointment Setting and Patient Communication Services services, such as helping you to book appointments with a UCA healthcare provider(s) (each, “UCA Healthcare Provider”) and managing and forwarding your health history forms and other health-related information to share with Your Healthcare Providers (“UCA Services”). As part of providing these UCA Services, UCA may collect, use, share, and exchange your health history forms and other health-related information with UCA Healthcare Providers. Under a federal law called the Health Insurance Portability and Accountability Act (“HIPAA”), some of this health and health-related information may be considered “protected health information” or “PHI” if such information is received from or on behalf of Your Healthcare Providers.
Safeguards for PHIHIPAA protects the privacy and security of your PHI by limiting the uses and disclosures of PHI by UCA and by health plans (called “Covered Entities”) as well as companies, that provide certain types of assistance to Covered Entities (called “Business Associates”). Under certain circumstances described in HIPAA, an individual needs to sign an Authorization form before a Covered Entity, like Your Healthcare Provider(s), can disclose protected health information to a third party.
Your PHI AuthorizationThe purpose of this UCA Authorization (“Authorization”) is to request your written permission to allow UCA to use and disclose your PHI in the same way as we use and disclose your Non-PHI. UCA needs your Authorization to be able to use and disclose your PHI in the same way it can currently use and disclose your Non-PHI when UCA is not working on behalf of UCA Healthcare Providers, but is instead working on its own behalf. Therefore, when UCA relies on this Authorization, and uses and discloses PHI as described in this Authorization, it is not working as a Business Associate and the HIPAA requirements that apply to Business Associates will not apply to such uses and disclosures.
If you e-sign this Authorization, you give your written permission to UCA to retain your PHI and to use and/or disclose your PHI in the same way that you have agreed that your Non-PHI can be used and disclosed.
Specifically, you agree that UCA can use your PHI to:
You also agree that UCA can disclose your PHI to:
If UCA discloses your PHI, UCA will require that the person or entity receiving your PHI agrees to only use and disclose your PHI to carry out its specific business obligations to UCA or for the permitted purpose of the disclosure (as described above). UCA cannot, however, guarantee that any such person or entity to which UCA discloses your PHI or other information will not re-disclose it in ways that you or we did not intend or permit.
Expiration and Revocation of Authorization
Your Authorization remains in effect until you provide written notice of revocation to UCA. YOU CAN CHANGE YOUR MIND AND REVOKE THIS AUTHORIZATION AT ANY TIME AND FOR ANY (OR NO) REASON. If you wish to revoke this Authorization, you must notify UCA by submitting a revocation through your account settings page. Your decision not to execute this Authorization or to revoke it at any time will not affect your ability to use certain of the UCA Services. A Revocation of Authorization is effective after you submit it to UCA, but it does not have any effect on UCA’s prior actions taken in reliance on the Authorization before revoked. Once UCA receives your Revocation of Authorization, UCA can only use and disclose your PHI as permitted in UCA’s agreements with Your Healthcare Provider(s). Your Revocation of Authorization does not affect UCA’s use of your Non-PHI. We will make available to Your Healthcare Provider(s), current and past, your agreement to or revocation of this Authorization.