CarePassport requires your signature and agreement to use and disclose your Protected Health Information. Kindly Read the HIPAA Authorization Statement and learn more about your medical information that will be used or disclosed by the app. Please agree to the HIPAA Authorization Statement to continue using CarePassport App.

CarePassport requires your signature and agreement to use and disclose your Protected Health Information. Kindly Read the Release Document and learn more about your medical information that will be used or disclosed by the facility. Please agree to the Release Document to continue using CarePassport App.

This authorization will terminate in one year unless otherwise specified. I understand that I may stop this release at any time by writing to CarePassport. Once the health information has been released to another facility or provider, there is no way to cancel or stop the release. I understand that when the health information is released the information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws. I understand that CarePassport will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign the consent form. I understand that I must sign this form to release my health information which may include History and physical, photographs, radiology reports, laboratory reports, discharge summary, radiology Images, emergency room report, progress/clinic notes, dental report/X-rays, surgery report, care plan, visits report, medications, immunizations or cardiac/EKG reports.