HIPAA Authorization

Adept Labs, Inc. d/b/a Junction (“Junction”) provides API solutions for at-home health care. Junction contracts with enterprise customers to grant access to Junction’s services to the customers’ patients like you. As part of its service, Junction works with health care providers and lab testing facilities to facilitate sharing your protected health information as governed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. § 1320d and 45 C.F.R. § 160–164.

This HIPAA Authorization is to authorize the disclosure of your information from Junction and the health care providers and laboratories that order or perform your lab tests through Junction to WellTheory Technologies, Inc. and its care team, including registered dieticians, nutritionists, health coaches, and care coordinators (“WellTheory”). By signing below, you agree as follows:

1. Pursuant to HIPAA, I authorize and direct Junction and the health care providers and laboratories that order or perform my lab tests through Junction to disclose to WellTheory the lab order(s), and/or lab testing results (including any related provider notes or interpretations) for lab tests that I request through the WellTheory Program.
2. The purpose of the uses and disclosures are to allow WellTheory to provide its program services to me, including care coordination, development of my personalized care plan, coaching and education, and program quality and outcomes measurement. WellTheory will not disclose my lab results to my employer, health plan, or any other organization that sponsors my access to WellTheory unless I separately authorize it or the law requires it.
3. I understand that, with certain exceptions, I have the right to revoke this Authorization at any time except to the extent that action has already been taken in reliance on it. If I want to revoke this Authorization, I must do so in writing. I may revoke this Authorization by sending an email to support@tryvital.io stating my desire to revoke my HIPAA Authorization. I understand that it may take Junction up to five (5) business days to process my revocation, and Junction will notify WellTheory of my revocation.
4. I understand that I may refuse to sign this Authorization. If I refuse, I will not be able to have lab tests ordered through Junction for the WellTheory Program, because the purpose of those tests is to share results with WellTheory. Refusing to sign will not affect my eligibility for, enrollment in, or payment of benefits under any health plan, or my ability to receive treatment from any other health care provider. I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by applicable federal medical privacy law and could be re-disclosed by the recipient. WellTheory will protect my information as described in the WellTheory Privacy Policy and applicable state law.
5. This Authorization will expire on the earlier of (a) one (1) year from the date I sign it, or (b) the date my participation in the WellTheory program ends, unless I revoke it earlier in writing as specified above.

I understand that I have a right to a copy of this Authorization.

By checking the box or clicking “I Agree,” I agree that my electronic signature has the same effect as a handwritten signature.