I hereby authorize SMARTKLINIC to share the health information contained in my SMARTKLINIC profile(s) in its entirety, to only those entities and individuals I designate, for the purpose of providing me with medical care and for the purpose of sharing my information with others that I choose.

I understand and agree that this authorization permits the disclosure of health or treatment information about me, to the entities and individuals I designate, that may also contain sensitive information relating to the following:

  • HIV or AIDS
  • Mental illness or any mental health condition
  • Alcohol or substance abuse
  • Sexually transmitted diseases
  • Pregnancy
  • Abortion or other family planning
  • Genetic tests or genetic diseases
I understand and agree that this authorization also covers any record that was created by me, a doctor or other health care provider other than the doctor or health care provider who supplied the record to SMARTKLINIC

This authorization will remain in effect and permit the ongoing disclosure by SMARTKLINIC of information in the SMARTKLINIC Continuous Care Service until I delete my profile(s) in the SMARTKLINIC Service entirely or revoke the authorization. I may revoke this authorization at any time by using the features or options described in the SMARTKLINIC Product feature. I understand that my revocation will not apply to actions SMARTKLINIC has already taken in reliance on my prior authorization.

I understand and agree that in addition to the information I choose to share, SMARTKLINIC may only share information in the limited circumstances described in the SMARTKLINIC Health Privacy Policy. I understand that I may request a copy of this authorization at any time.


Date : December 2017