HIPAA AUTHORIZATION

We respect your privacy. Ensuring that medical information is kept confidential is among our highest priorities. We seek your consent to allow us to use your health formation that you share with us in the course of our Consumer Survey as permitted in this authorization. To ensure that we are acting in accordance with your wishes, and using your health information with your authorization, by clicking agree you approve this authorization. We will keep a copy of your authorization on file.

By clicking agree, I authorize 1Life Healthcare, Inc. and our affiliates to use, disclose, copy, reproduce, distribute, transmit, modify, display, perform, publish and otherwise use my protected health information, and details of my medical care, treatment, and experience as a patient that I provide to 1Life, including without limitation, content in audio, video, photographic, text or other form, in communications, reports and publications produced by or on behalf of 1Life, and to use and distribute such communications, reports, and publications in any medium for 1Life’s internal business purposes worldwide.

MY RIGHTS

• I understand that this authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on my signing this authorization.
• If I decide to sign this form, I have the right to request that audio/video recording, filming or photographing cease at any time.
• I understand that I may revoke or alter this authorization at any time, that I must do so in writing and submit it to 1Life. However, I understand if I revoke this authorization, it will not have any effect on actions 1Life took before they received my revocation.
• I am aware that my protected health information will exist forever in either a recorded, printed, and/or electronic version or other version as may develop over time.
• I understand that I am entitled to request and receive a copy of this authorization.