HIPAA Authorization

You are entitled to keep your protected health information private. This Authorization allows you to grant permission for uses and/or disclosures of your protected health information that otherwise would not be permitted by the Health Insurance Portability and Accountability Act, or “HIPAA.” By indicating your consent by checking the box on our website indicating that you consent to have your personal health information being used and disclosed for the purpose of providing your healthcare as described in the present form, you authorize the relevant medical group (“Medical Group”) to use and disclose the protected health information described below: (a) to the named persons or entities, and (b) for the purposes identified in this form.

Medical Groups:

Depending on your particular case, the Medical Group will be one listed below: 

-Vira Health,Inc. affiliates and subsidiaries including Vira Health (IL), PLLC and Vira Health (CA), PC.

– Cloud Health Medical Group.

I hereby authorize the release of the following protected health information: 

• My medical information, including test results, medical conditions, allergies, prescription information, health insurance, health-related information relevant to my telehealth consultation, information generated by my interactions with a Medical Group or a Provider (where “Provider” means a physician employed or contracted by the Medical Group). 

This information may be released to: 

• Vira Health Limited
• Vira Health, Inc.

Both referred to as (“Vira”)

This information may be used for the purpose of: 

• Providing   you with access to personalized menopause care and support, including from clinicians, and from all other Stella services. 
• Assessing your insurance coverage and charging you accordingly. 

I also understand and agree to the following:

• I may refuse to provide this Authorization. However, if I do not provide this Authorization, I will not be able to access care from the clinicians (as related to the Stella services), or access any other Stella services requiring my consent.
• Any information used or disclosed because I have agreed to this Authorization may no longer be protected by privacy laws and may be subject to re-disclosure by the person or organization receiving it.
• I have the right to revoke this Authorization at any time by doing so in writing to privacy@vira.health. 
• Any revocation of this Authorization by me will not apply to actions already taken regarding the sharing of my protected health information during the period of time that my Authorization was effective.
• This Authorization will remain in effect from the date it is consented to unless otherwise revoked.

By checking the consent box, I confirm having read this document and confirm that I had an opportunity to ask questions about this Authorization by writing to privacy@vira.health and I agree to its terms.