Authorization for Use or Disclosure of Health Information
Patient’s Full Name:
Address:
Email:
Address:
Date of Birth:
1. My provider uses Wave Neuroscience software technology to assist with delivery of my health care services and treatment planning, and I have voluntarily agreed to use the Wave Neuroscience MeRT Patient Portal (the “Portal”) in connection with my plan of care. Wave Neuroscience respects your privacy and your ability to make your own decisions about how your information can be used.
2. I hereby authorize Wave Neuroscience to use or disclose my health information contained in the Portal, regardless of when such information was created, for the purpose of creating de-identified information sets that will be combined with de-identified information sets of other patients to create aggregated, de-identified data sets that Wave Neuroscience and its agents or contractors may use for the following purposes:
- to improve Wave Neuroscience’s products and services, including to achieve more precise measurements and protocol recommendations;
- for research and development of new products and services; and
- to train artificial intelligence (AI) or machine learning (ML) technologies to assist in delivery of new or existing products and services.
3. The types of health information that may be used to create de-identified information sets include my:
- Demographic information, including my age and gender
- Medical condition or diagnosis
- Plan of care
4. I understand that I may revoke this authorization at any time by emailing privacy@waveneuro.com, except to the extent that action has already been taken by Wave Neuroscience in reliance upon this authorization. If not previously revoked, this authorization will terminate when my provider terminates its relationship with Wave Neuroscience, unless applicable state law requires the application of an earlier date (such as 1-year from the date of signature), in which case, we will follow applicable law.
5. I further understand, however, that once an information set has been properly de-identified, it no longer contains personally identifiable information about me, is no longer protected under HIPAA, and may be retained and used by WaveNeuroscience for the purposes stated herein after this authorization expires or is terminated. For more information about de-identified information,
visit https://www.hhs.gov/hipaa/for-professionals/special-topics/de-identification/index.html.
6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
7. The information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by Federal law.
8. I will not receive any financial compensation for the use or disclosure of my information as described in this form.
9. I understand that I am entitled to a copy of this authorization.
Printed Name:
_______________________________________________
Patient/Parent/Guardian/LegalRepresentative Signature:
_______________________________________________
Date:
________________________________
Relationship to Patient:
_______________________________________________