HIPAA Authorization | Stella

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 below, you authorize OpenLoop Healthcare Partners, PC (“OpenLoop”) 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.

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

  • My medical information, including test results, medical conditions, allergies, prescription information, generated by my interactions with an OpenLoop clinician

This information may be released to:

  • Vira Health Limited (“Vira”)

This information may be used for the purpose of:

  • To provide you access to personalized menopause care and support, including from clinicians, and from all other Stella services

I also understand and agree to the following:

  • I will receive an electronic copy of this Authorization form for my records.

  • I may refuse to provide this Authorization. However, if I do not provide this Authorization, I will not be able to access care from OpenLoop clinicians (as related to the Stella services), or access any other Stella services.

  • 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 317 6th Avenue, Suite 400, Des Moines, Iowa 50309

  • Any revocation of this Authorization by me will not apply to actions that OpenLoop has 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 signed unless otherwise revoked.

I have read and had an opportunity to ask questions about this Authorization and agree to its terms.