HIPPA Transfer Authorization Policy - Klarity

Information Authorized for Disclosure

I authorize the following persons and organizations to disclose my protected health information (PHI), as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended:

• Any and all healthcare providers (e.g., physicians, nurses, aides, pharmacies, therapists, counselors, technicians)
• Insurers and/or third-party administrators who may have possession or custody of my PHI.

This includes medical records, billing information, diagnostic results, treatment notes, and other relevant health information.

Recipients of Information

The following organization and its affiliates are authorized to receive my PHI:

• Klarity Health, Inc., its affiliates, and agents ("Klarity")
• Myself (the patient)

Purpose of Disclosure

I authorize Klarity to receive my PHI for the following purposes:

1. Claim processing
2. Scheduling appointments
3. Transferring information to another provider for purposes of care continuity
4. Administrative matters related to healthcare services I receive using Klarity's platform

This authorization also permits a representative of Klarity to conduct a personal review of all my PHI and to discuss this information with the disclosing healthcare provider(s).

Expiration and Revocation

• Expiration: Unless I revoke it earlier, this authorization will expire five (5) years from the date of signature or at the conclusion and settlement of my personal injury claim, whichever is later.
• Right to Revoke: I may revoke this authorization at any time by submitting a written notice to all healthcare providers where this authorization was filed. Revocation will not apply to information that has already been released based on this authorization.

Your Rights and Important Information

• Voluntary Authorization: Signing this form is voluntary. I understand that I do not have to sign this form to receive treatment, payment, enrollment, or eligibility for benefits.
• Right to Inspect or Copy: I have the right to inspect or request a copy of the PHI disclosed under this authorization.
• Disclosure Risks: Once disclosed, my PHI may be subject to re-disclosure by Klarity and may no longer be protected under federal or state law. For more details about how Klarity protects my information, I can review their privacy policies.
• Copy of Authorization: I will receive a signed copy of this form. A photocopy or digital copy of this authorization will be treated the same as the original.

Contact Information for Questions or Concerns

If I have questions about this authorization, I can contact:

• Klarity Health, Inc. at compliance@helloklarity.com