Purpose

This authorization permits ShadowNurse, Inc. to assist me during my medical care by participating in my appointments, receiving protected health information related to those appointments, and coordinating follow-up support at my direction.

Authorization to Participate in Medical Visits

I authorize ShadowNurse, Inc., including its nurses, care navigators, and administrative staff, to participate in my medical visits in a remote capacity. This includes telephone participation, video participation, or audio-only presence during any in-person or telehealth appointment when I choose to involve ShadowNurse. I understand that my ShadowNurse representative may hear and discuss information shared during these clinical encounters.

Authorization to Receive and Disclose Protected Health Information

I authorize any of my health care providers, health plans, and clinical entities involved in my care to disclose to ShadowNurse information relevant to my treatment, care coordination needs, medical history, medications, diagnoses, visit notes, eligibility information, and scheduling. This includes independent clinical entities involved in my care, such as OpenLoop Healthcare Partners, PC, and any future medical groups that may provide clinical services coordinated through ShadowNurse.

This authorization permits ShadowNurse to use the information disclosed to assist me with understanding my medical care, preparing for and following up on appointments, coordinating recommended services, and supporting my ongoing care navigation. This authorization also permits ShadowNurse to disclose information back to my health care providers when necessary for care coordination or as directed by me.

Description of Information to Be Disclosed

This authorization includes information shared during my medical visits as well as information exchanged outside those visits. It covers medical and administrative information relevant to my care, including written, verbal, and electronic communications. This may include diagnoses, treatment plans, medications, lab and imaging results, visit notes, after-visit summaries, referrals, care plans, scheduling information, insurance and eligibility details, and other records needed for care coordination.

Voluntary Nature of This Authorization

Signing this authorization is voluntary. My decision to sign or not sign will not affect my ability to receive medical care, obtain insurance benefits, or use ShadowNurse’s services, except to the extent that ShadowNurse may be unable to assist me during medical visits without this authorization.

Right to Revoke

I may revoke this authorization at any time by notifying ShadowNurse in writing at [hello+HIPAA@shadownurse.com]. Revocation does not affect information already disclosed or relied upon before the revocation was received.

Expiration

This authorization does not expire unless I revoke it in writing.

Redisclosure

I understand that information disclosed to ShadowNurse may no longer be protected by HIPAA privacy rules if ShadowNurse is not acting as a HIPAA covered entity or business associate with respect to certain activities. ShadowNurse will safeguard my information according to its Privacy Policy.

Acknowledgment*

I have read and understand the terms of this authorization. I may request a copy for my records.

Signature _______________________________

Name __________________________________

Date ___________________________________

* Your agreement to this authorization is documented through your electronic signature when you check the required authorization box within the ShadowNurse intake process. That electronic acknowledgment constitutes your signature for this authorization.