Authorization for Use & Disclosure of Information (Marketing Purposes) for OnlineUTImeds.com and its website UTIRX.com
Information to Be Used and Disclosed
I authorize health-care providers contracted with OnlineUTImeds.com, LLC ("OnlineUTImeds.com"), and their independent medical groups and pharmacies (collectively, the "Providers") to use and disclose to OnlineUTImeds.com and its affiliated entities (collectively, “Affiliates”) the following information that I supply or that is collected during my care:
- Identifiers: name, date of birth, address, telephone number(s), email address.
- Protected Health Information (PHI): medical history, diagnoses, prescription details, refill history, laboratory data, and pharmacy information.
- Sensitive information that may reveal mental-health conditions, substance-use disorder, HIV or other communicable diseases, genetic data, or developmental disabilities.
Purpose of the Authorization
- The PHI listed above may be used or disclosed solely to:
Send me marketing or promotional communications—such as prescription-pricing offers, coupons, refill reminders, and information about pharmaceutical, medical, or laboratory services—via the contact details in my OnlineUTImeds.com profile; and - Allow OnlineUTImeds.com or its Affiliates to receive direct or indirect compensation for such marketing activities.
Your Rights Concerning This Authorization
- Voluntary & No Conditions of Care. Refusal to sign will not affect your treatment, payment, enrollment, or eligibility for benefits.
- Revocation. You may revoke this Authorization at any time by emailing [email protected] or writing to the Privacy Officer listed below.
- Revocation will not affect any use or disclosure already made in reliance on this Authorization.
- Potential for Re-disclosure. Information disclosed to Affiliates under this Authorization may be re-disclosed and may no longer be protected under HIPAA. However, Affiliates are contractually required to safeguard your PHI.
- HIPAA Privacy Rights. You retain all rights described in our Notice of Privacy Practices (NPP), including the rights to access, amend, restrict, or receive an accounting of disclosures of your PHI, request confidential communications, and file a privacy complaint.
Our Legal Duties
OnlineUTImeds.com is a HIPAA-covered entity and is required by law to maintain the privacy and security of your PHI. We will use or disclose your PHI for marketing only as permitted by HIPAA and this Authorization, or as otherwise required by law. We will provide you with written notice of any breach of your unsecured PHI as defined by HIPAA.
Privacy Official & Contact Information
If you have questions about this Authorization or our privacy practices, or wish to exercise your HIPAA rights, contact:
Privacy Officer: Dr. Arash Rafiei
OnlineUTImeds.com, LLC
Email: [email protected]
Expiration
This Authorization remains in effect until the earliest of:
The date you revoke it in writing
You acknowledge that you have read and understand this Authorization and voluntarily grant OnlineUTImeds.com and its Affiliates permission to use and disclose your information as described above.
