HIPAA Waiver

Authorization for Use and Disclosure of Protected Health Information

By checking this box, I authorize Mending to use and disclose any of my personal health information maintained by Mending with any provider, care coordinator, or partner organization affiliated with or contracted by Mending for the purposes of care coordination, follow-up, and connecting me to appropriate services.

This may include information about my medical history, preventive care, medications, or social needs.

For members enrolled in a Direct Primary Care Plan, Mending may disclose a member’s Protected Health Information (PHI), including member name, address, email, telephone number, and plan enrollment status, to in-network direct primary care providers.

Direct primary care providers may use PHI to contact members for purposes of care coordination and treatment, including:

• Informing members about availability of direct primary care services,
• Helping members establish or transfer a primary care relationship,
• Providing reminders and resources related to preventive care, chronic condition management, and wellness programs.

I understand that:

• This authorization is voluntary.
• I may revoke it at any time by emailing support@mending.com or sending the request in the mail to:

Important Information:

• Revocation will not apply to information already shared before my revocation.
• In Maine: This authorization will remain in effect until the earlier of (i) thirty (30) months from the date of authorization, or (ii) the date I am no longer enrolled in any health plan offered by Mending, unless revoked sooner in writing. Once this authorization expires, a new authorization must be provided for any further use or disclosure of information.
• In Georgia and Oklahoma: This authorization will remain in effect until the date I am no longer enrolled in any health plan offered by Mending, unless revoked sooner in writing. Once enrollment ends, this authorization will automatically expire.
• Once information is disclosed, it may no longer be protected by HIPAA.