If you opt to use certain services or products provided by GoodRx, such as booking healthcare appointments via GoodRx, GoodRx may receive certain information that is held by your health care providers and health plans may be considered “protected health information” or “PHI” under the Health Insurance Portability and Accountability Act (“HIPAA”).
Authorization for Use and Disclosure
The purpose of this Authorization (“Authorization”) is to allow Covered Entities identified below to disclose to GoodRx, Inc. and affiliates and subsidiaries of GoodRx, Inc. (“GoodRx”) certain information about you, as further described below.
Covered Entities include your past or current healthcare providers, prospective healthcare providers for whom we display information, and your past or current insurance plan. If you opt to use certain services or products provided by GoodRx, GoodRx may receive your information from these Covered Entities.
The information that you are requesting be disclosed by your Covered Entities to GoodRx includes your insurance coverage information, medical information, prescription and prescription-related information, and pharmacy name and other contact information. If your medical information, prescriptions and/or prescription-related information include information regarding any sensitive medical conditions you may have, including but not limited to those related to mental health, substance use, HIV or other communicable diseases, developmental disabilities, and/or genetic conditions, you authorize that information to be used and disclosed pursuant to this Authorization.
By clicking “agree” below, you request that these Covered Entities provide GoodRx your information described above for the following purposes: to permit GoodRx to provide you with its services and products, directly or via a third party, to send you information to you about products and services that may be of interest to you offered by GoodRx or third parties, to enable and customize the use of GoodRx’ s services and products for you, to provide you with updates and information about GoodRx, to permit GoodRx to develop new products and services and analyze its existing products and services, to support development of the GoodRx services and to communicate with your health care providers.
Expiration and Revocation of Authorization
You may revoke this Authorization by providing written notice of revocation to GoodRx by emailing email@example.com with the subject line “Revocation of HIPAA Authorization.”
YOU CAN CHANGE YOUR MIND AND REVOKE THIS AUTHORIZATION AT ANY TIME AND FOR ANY (OR NO) REASON.
Not agreeing to this Authorization or revoking it at any time will not prevent you from receiving treatment or payment for treatment from your Covered Entities, but you understand that it may prevent you from being able to use all of the products and services offered by GoodRx. You are not required to agree to this Authorization.
You understand that if you sign this Authorization, information disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy law. A revocation of Authorization is effective after it is received and processed by the applicable Covered Entities, but it does not have any effect on actions taken in reliance on this Authorization before the Revocation is effective.
You are entitled to receive a copy of this Authorization. To do so, please contact: firstname.lastname@example.org.
By checking the related box, you are confirming that this Authorization accurately reflects your wishes with respect to the use and disclosure of your health information. In the event you are making a request on another’s behalf, you certify you are the legal representative of the individual who is the subject of this authorization.