I hereby authorize Solera Specialty Pharmacy,LLC and their employees, agents and contractors (collectively “Solera Pharmacy”), to use or disclose, as specified in this Authorization, my “protected health information” that is covered under privacy regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA Privacy Rule”). I understand that “protected health information” includes records disclosed to Solera Pharmacy by health care providers and facilities that previously provided treatment to the Patient. I also understand that “protected health information” may include information and records protected under Federal Law (such as alcohol and drug abuse treatment information) and/or protected under State Law (such as mental health treatment or related communications, or information relating to testing or treatment for AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus)). I specifically request and authorize release of information in my records regarding HIV and/or AIDS, if such information is contained in my records.
I understand that I may revoke this Authorization by submitting a written revocation to the Pharmacy Manager of the Solera Pharmacy location which serves me, provided that such revocation shall not be effective with respect to any use or disclosure made by Solera Pharmacy in reliance on this Authorization prior to the date of Solera Pharmacy’s receipt of my revocation. I understand that Solera Pharmacy cannot require me to sign this Authorization in order receive treatment unless the provision of health care by Solera Pharmacy is solely for the purpose of creating protected health information for disclosure to a third party or for research-related treatment, in which situations Solera Pharmacy will not provide the service unless I sign this Authorization. I understand that the information used or disclosed by Solera Pharmacy pursuant to this Authorization may be subject to re-disclosure by the recipient in which case it might no longer be protected under the HIPAA Privacy Rule. However, I understand that in some cases, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements. I authorize Solera Pharmacy to copy this Authorization and to send the recipient the re-disclosure notice required under the Federal Substance Abuse Confidentiality Requirements, whether or not my records contain information protected by those laws.
I have read and understood this Authorization and my questions have been answered. I certify that I am the Patient listed above or a person authorized to permit release of records on Patient’s behalf. I hereby release Solera Pharmacy (as defined above) from any liability arising in connection with the use or disclosure of my protected health information pursuant to this Authorization.