Effective Date: 11/17/2022
- By linking your Doctor on Demand account to your Included Health account, you are authorizing the disclosure of any and all Doctor on Demand medical and billing records to Included Health.
- Once your accounts are linked, your visit history, lab tests, providers, prescriptions, appointments, and pharmacies from your Doctor on Demand account will now be associated with your Included Health account. Any future clinical information collected will be associated with both your Included Health and Doctor on Demand account.
- When accessing care, your care and clinical team will be able to see your full medical history across your Included Health and Doctor on Demand accounts.
- When updating any of your personal information like name, email address, address, gender, and/or phone number within the Included Health or Doctor on Demand app, your updated personal information will be synchronized across both apps.
- It’s possible medical records used or disclosed based on this authorization may be re-disclosed by a recipient, and privacy laws may no longer protect the information. Some information, such as substance use disorder or behavioral health information may still be protected.
- I authorize the disclosure of information relating to (as applicable) genetic testing, information, and indicators; substance use disorder information; behavioral health and psychiatric evaluations and treatment; and sexually transmitted and other communicable diseases, including without limitation HIV/AIDS.
- My treatment, payment, enrollment, or eligibility for benefits or health services may not be conditioned on whether or not I sign this form.
- I may revoke this authorization in writing at any time. The revocation will be effective upon receipt, but will not apply to information that has already been released, or to services already provided. To revoke this authorization, please contact (email/phone number/address).