Patient Authorization
I hereby authorize any health plan, physician, health care professional, hospital, clinic, pharmacy or other health care provider to disclose my personal health information relating to my medical condition, treatment (including prescription information), care management and health insurance, as well as all information provided through this BlueStar Diabetes Self-Management Medical Software to Welldoc, Inc., its affiliates and their representatives, agents and contractors (collectively, "Welldoc") for purposes of managing BlueStar Diabetes Self-Management Medical Software and providing related services (including but not limited to, investigating insurance coverage; obtaining payment; fulfilling and coordinating delivery; assisting with product training, and providing product support); any internal business use by Welldoc, and to comply with the law. Welldoc may also de-identify my information and share the de-identified information with others for any purpose. I understand that once disclosed to Welldoc, my information may no longer be protected by federal privacy laws and may be re-disclosed by Welldoc; however Welldoc has agreed that it will not disclose my information except for the purposes stated in this authorization. I understand that I may refuse to agree to this authorization, and my refusal will not affect the commencement, continuation or quality of my treatment by my health care provider(s) or my enrollment or eligibility for health benefits. This authorization expires 5 years after the date of my acceptance, unless I revoke it earlier by sending written notice of revocation to BlueStar Customer Care, P.O. Box 1245, Columbia, MD 21044. I understand that any revocation will not affect any actions taken by my health care provider(s) or health plan(s) based on this authorization before they receive notice of my revocation. I understand I may receive a copy of this authorization once signed. I confirm that my name and insurance information provided is correct.