I understand and agree that I give permission to providers to use and disclose my protected health information including my entire medical record. This protected health information is being used or disclosed for the purpose of telehealth treatment. This authorization expires when you contact rx@intimaterose.com.

1. If the person or entity receiving this information is not a health care provider or health plan covered by HIPAA, the information described above may be redisclosed to other individuals or institutions and therefore no longer protected by HIPAA.
2. I may refuse to agree to this authorization. My refusal to sign will not affect my payment, ability to obtain treatment, or eligibility for health plan benefits unless this authorization is requested prior to research related to treatment, enrollment in a health plan, or providing health care that is solely for the purpose of giving that information to a third party, such as to a court for a legal proceeding.
3. I may inspect or copy the protected health information to be used or disclosed under this authorization. For protected health information created as part of a clinical trial, your right to access is suspended until the clinical trial is completed.
4. I may revoke this authorization in writing at any time by sending a written notification to Privacy Officer at 1419 Murray St. North Kansas City 64116. Your notice of revocation will not apply to actions taken by providers prior to the date of receipt of the notice.

Your privacy is important to us. By using our telehealth service, you consent to the use and sharing of your health information for treatment purposes in accordance with applicable privacy laws. Communications via text or email (if enabled) are not considered secure, and you accept the risk of receiving non-sensitive information through those channels.