HIPAA Consent and Authorization Form - Thrive OBGYN

I hereby authorize the use and disclosure of my fertility cycle data, as shall be recorded by Tempdrop’s fertility monitor and generated by this Application, including any additional personal information I will insert into the Application (all the foregoing information: “My PHI”) by Tempdrop to “Thrive OBGYN” (the “Clinic”) for purposes of supporting fertility treatments

I understand that My PHI are protected under federal law, including 42 CFR Part 2 and HIPAA, and any applicable state laws. My PHI can only be used or disclosed with my written consent, except as permitted by 42 CFR Part 2, HIPAA, and applicable state law.

I understand that I have the right to revoke my consent to disclose My PHI to the Clinic at any time. To do so I understand that I may withdraw my consent via the Application, which will take effect immediately, or by submitting my revocation in writing to clinic@temp-drop.com, which will take effect within 48 hours. Once the revocation is effective, my PHI will no longer be disclosed to the Clinic.

I also understand that a written revocation is not effective with respect to actions that Tempdrop or the Clinic took in reliance on my valid authorization as stated above, or where my authorization was obtained as a condition of obtaining insurance coverage.