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Authorization to Use or Disclose Protected Health Information (PHI)

  1. Golden Valley Memorial Healthcare (GVMH) is authorized to allow this use or disclosure per the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  2. I understand that the information accessed through myGVMH Health Portal will only include dates of service after December 1, 2018.
  3. I understand that I am authorizing access to my electronic patient information, which may include my lab results, discharge instructions and summaries, allergies, diagnosis list, medications, vitals and appointments. There may be specific tests excluded at the decision of GVMH. I also understand that I may have access to any medical record information excluded from myGVMH Health Portal by following release-of-information policies established by GVMH.
  4. I understand that the information in my health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, treatment for alcohol and drug abuse, or serious communicable diseases as defined by the Department of Public Health, including hepatitis B, venereal disease and tuberculosis.
  5. I understand that myGVMH Health Portal does not provide internet-based diagnostics, triage, or other medical services.
  6. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the director of health information management. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest and access my records in accordance with my policy.
  7. I understand that once the above information is disclosed, it may be redisclosed by the recipient, and the information may not be protected by federal privacy laws or regulations, although such use/disclosure may be subject to other Missouri and federal laws.
  8. I agree that the provided email address is correct, and I will not hold GVMH or any of its staff liable for network breaches beyond its control.
  9. I understand that access to myGVMH Health Portal is an optional service and may be suspended or terminated at any time for any reason.
  10. Participation is voluntary. GVMH reserves the right to discontinue at any time.