(Effective March 1, 2023)
I hereby authorize Function Health and its affiliates (“Function”), to use my medical information for the purposes listed below. Failing to provide all information requested may invalidate this Authorization.
My authorization applies to the following types of information: all of my individually identifiable medical information as received by Function, including my name, birthdate, contact information (such as e-mail, address, phone number), demographic information, and any other information pertaining to my medical history, mental or physical condition, or treatment.
The purpose of this Authorization is to permit Function to: use the information listed above in connection with marketing, advertising, and promotional activities by Function regarding: (a) the release, availability, details, specifications, features, quality, performance, and/or price of one or more products, services, and/or opportunities offered by Function and/or a third-party; and/or (b) news, current events, research, history, and advances in science, health, wellness, nutrition, personal care, and/or technology that Functions deems may be of interest to you.
I acknowledge and understand that Function may receive compensation for such uses of my medical information.
My rights. I understand that:
· Any use or disclosure carries the potential for unauthorized re-disclosure. Such redisclosure is in some cases not prohibited by state law and may no longer be protected. California law prohibits the recipient of my medical information from making further disclosures unless the recipient obtains another authorization from me or unless such disclosure of medical information is required/permitted by law.
· I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to Function at the address listed below.
· My revocation will be effective upon receipt, but will not be effective to the extent that Function or others have acted in reliance upon this Authorization.
· I have a right to receive a copy of this Authorization. I may inspect or obtain a copy of the medical information used or disclosed subject to this Authorization.
Unless otherwise revoked by me, this Authorization shall be effective for five (5) years from the date of my approval.
I have read and understand the above statements, and authorize the use of my medical information by Function as identified in this Authorization.
For questions, please contact Function:
Function Health
3515 Longmire Drive Ste B #288
College Station, TX 77845
legal@functionhealth.com