Authorization to Release Protected Health Information (PHI)

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I hereby authorize my healthcare provider, hospital, or other facility involved in my cancer care, including

to release health information to SageMedic Corp. (SAGE), 555 Twin Dolphin Drive, Ste 110, Redwood City, CA 94065. I also authorize SAGE to release the results of the SAGE HT Oncotest™ to my healthcare providers, including any other hospital and/or facility involved in my cancer care.

Authorized Protected Health Information (PHI)
The authorized protected health information (PHI) includes medical records related to my current cancer diagnosis including, but not limited to, history & physical, consult notes, operative reports, discharge summary, lab results, diagnostic and radiology reports.

The purpose of this release is for (check all that apply):
Information may be released (check one or more):

Expiration of authorization
The authorization is voluntary, will expire in 60 months after I have signed this form. I may also revoke my authorization in writing anytime, but any action taken in reliance on this form prior to the date of my revocation will neither be reversed not will it subject SageMedic to any liability for any such actions.

HIPPA3 Notice
If I consent to receive information by e-mail, I understand and acknowledge that communicating my health information via ordinary unencrypted emails has inherent risks, specifically the loss of privacy. Any clinically relevant health information may be incorporated into my medical records at my provider’s discretion. By signing below, I agree to hold SageMedic Corp. harmless for unauthorized use, disclosure, or access of my protected health information sent to the email address(es) I provide.

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