Greensboro DRI UFE Intake

Last Updated: May 5th 2024 &#13;&#10;DRI, LLC ('Practice') has engaged EngageCare LLC ('EngageCare') to provide services to evaluate your clinical needs and connect you with Practice to schedule and manage appointments (collectively, the “EngageCare Services”) by collecting and sharing your personal and health-related information with Practice.&#13;&#10;&#13;&#10;As part of providing the EngageCareServices, EngageCare may collect, use, share, and exchange your personal information, including health-related information, with Practice. You agree that EngageCare can disclose your PHI (read definition below) to third parties assisting EngageCare with any of the uses described above including third parties providing online tracking technology services to EngageCare, these 3rd parties include, but are not limited to Google LLC and Meta Platforms, Inc which runs the Facebook and Instagram brands. EngageCare may send at least an IP address or a hashed email address to 3rd parties and may disclose more PHI and other information.&#13;&#10;&#13;&#10;Under a federal law called the Health Insurance Portability and Accountability Act (“HIPAA”), this health-related information may be considered “protected health information” or “PHI” if such information is created, received, transmitted and/or maintained for or on behalf of Practice.&#13;&#10;As a condition of engaging with EngageCare Services, you are required to read and agree to EngageCare’s Privacy Policy. EngageCare’s Privacy Policy explains how EngageCare processes and shares PHI and other personal information received from you.&#13;&#10;&#13;&#10;Safeguards for PHI HIPAA protects the privacy and security of your PHI by limiting the uses and disclosures of PHI by most healthcare providers and by health plans (called “Covered Entities”) as well as companies, like EngageCare, that provide certain types of assistance to Covered Entities (called “Business Associates”).&#13;&#10;Under certain circumstances described in HIPAA, an individual needs to sign an Authorization form before a Covered Entity, like your Healthcare Provider(s), can disclose protected health information to a third party.&#13;&#10;'Your Authorization for Collection, Use and Disclosure ("Authorization"). The purpose of this Authorization is to request your written permission to allow EngageCare to use and disclose your PHI in the same way as we use and disclose your other personal information in accordance with our Privacy Policy.&#13;&#10;If EngageCare is a Business Associate of Practice, EngageCare needs your Authorization to be able to collect, use and disclose your PHI in the same way it can currently use and disclose your other personal information when EngageCare is not working on behalf of Practice, but is instead working directly on your behalf or on its own behalf.&#13;&#10;&#13;&#10;Therefore, when EngageCare relies on this Authorization, and collects, uses or discloses PHI as described in this Authorization, it is not working as a Business Associate and the HIPAA requirements that apply to Business Associates will not apply to such uses and disclosures.&#13;&#10;If you e-sign this Authorization, you give your permission to EngageCare to retain your PHI and to use and/or disclose your PHI in the same way that you have agreed that your other personal information can be used and disclosed.&#13;&#10;Specifically, you agree that EngageCare can use your PHI to:&#13;&#10;· enable and customize your use of the EngageCare Services;&#13;&#10;· provide you alerts or other communications regarding current and future EngageCare Services;&#13;&#10;· notify you regarding Practice and its services which we think you may be interested in learning more about;&#13;&#10;· share information with you regarding services, products or resources about which we think you may be interested in learning more;&#13;&#10;· provide you with updates and information about the EngageCare Services;&#13;&#10;· market to you about EngageCare and third party products and services;&#13;&#10;· conduct analysis for EngageCare’s business purposes;&#13;&#10;· support development of the EngageCare Services; and&#13;&#10;· create de-identified information and then use and disclose this information in any way permitted by law, including to third parties in connection with their commercial and marketing efforts.&#13;&#10;&#13;&#10;You also agree that EngageCare can disclose your PHI to:&#13;&#10;· Third parties assisting EngageCare with any of the uses described above including third parties providing online tracking technology services to EngageCare, these 3rd parties include, but are not limited to Google LLC and Meta Platforms, Inc which runs the Facebook and Instagram brands. EngageCare may send at least an IP address or a hashed email address to 3rd parties and may disclose more PHI and other information;&#13;&#10;· Practice to enable it to contact you to make appointments or to perform an analysis on potential health issues or treatments, provided that you choose to use the applicable EngageCare Service;&#13;&#10;· a third party as part of a potential merger, sale or acquisition of EngageCare;&#13;&#10;· our business partners who assist us by performing core services (such as hosting, billing, fulfillment, or data storage and security) related to the operation or provision of our services, even when EngageCare is no longer working on behalf of Practice;&#13;&#10;· a provider of medical services, in the event of an emergency; and&#13;&#10;· organizations that collect, aggregate and organize your information so they can make it more easily accessible to your providers.&#13;&#10;&#13;&#10;Redisclosure&#13;&#10;If EngageCare discloses your PHI to a third party, EngageCare does so only so the third party can carry out specific business obligations to EngageCare or for the permitted purpose of the disclosure.&#13;&#10;EngageCare cannot, however, guarantee that any such recipient of your PHI pursuant to this Authorization will not re-disclose it in ways that you or we did not intend or permit.&#13;&#10;&#13;&#10;Expiration and Revocation of Authorization&#13;&#10;Your Authorization remains in effect until you provide written notice of revocation to EngageCare.&#13;&#10;YOU CAN CHANGE YOUR MIND AND REVOKE THIS AUTHORIZATION AT ANY TIME AND FOR ANY (OR NO) REASON.&#13;&#10;If you wish to revoke this Authorization, you must notify EngageCareby submitting a revocation by contacting us at hipaa@engagecare.io.&#13;&#10;Your decision not to execute this Authorization or to revoke it at any time will not affect your ability to use certain of the EngageCare Services.&#13;&#10;A Revocation of Authorization is effective after you submit it to EngageCare, but it does not have any effect on EngageCare’s prior actions taken in reliance on the Authorization before revoked.&#13;&#10;EngageCare will not condition your treatment, payment, enrollment or eligibility for benefits on this authorization.&#13;&#10;&#13;&#10;Once EngageCare receives your Revocation of Authorization, EngageCare can only use and disclose your PHI as permitted inEngageCare’s agreements with Your Healthcare Provider(s).&#13;&#10;Your Revocation of Authorization does not affect EngageCare’s use of your other personal information which shall continue to be governed by EngageCare’s Privacy Policy.&#13;&#10;Upon request, we will make available to Your Healthcare Provider(s), your agreement to or revocation of this Authorization.

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