HIPAA Authorization for Use and Disclosure of Protected Health Information (PHI)

By clicking “SHOW ME WHAT I QUALIFY FOR”, I authorize Diabetes Advocates (diabetesadvocates.care) to use and disclose my Protected Health Information (“PHI”) including medical conditions, diagnoses, treatment history, medication/device usage, monitoring data, demographic and contact information linked to health data. I authorize use/disclosure for purposes of evaluating eligibility for diabetes-related programs, matching me with providers, care coordination programs, telehealth services, pharmacies, medical device providers, pharmaceutical companies, wellness programs, clinical trials, healthcare-related organizations, and legal advocacy groups. I understand Diabetes Advocates may receive compensation including referral fees or lead generation payments in exchange for disclosures where permitted by law. I understand this authorization is voluntary and not required for treatment or benefits. This authorization remains effective until revoked, account deletion, or 3 years from authorization date. I may revoke by contacting: [email protected] I understand once disclosed, data may no longer be protected under HIPAA. By clicking “SHOW ME WHAT I QUALIFY FOR”, I electronically sign and consent to this authorization.

Sensitive Health Data Consent

For Residents of Certain U.S. States, including your state.

By clicking “SHOW ME WHAT I QUALIFY FOR”, you provide your affirmative, informed, and voluntary consent to Diabetes Advocates to collect, process, analyze, and disclose your sensitive personal data, including health-related information, as described below. Your click constitutes your electronic signature, express written consent, and affirmative acceptance of this Consent.

1. Consent to Process Sensitive Health Data
By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to collect and process your sensitive personal data, including health-related information that you provide, such as:

• diabetes diagnosis, status, or condition
• treatment history
• medications or therapies
• glucose monitoring information
• device usage information
• diabetes-related health goals and preferences
• related health conditions or risk factors
• contact and demographic information associated with your health information

This information is considered sensitive personal data under applicable state privacy laws. You expressly authorize Diabetes Advocates to process this information to evaluate your eligibility for diabetes-related programs, services, and resources.

2. Consent for Eligibility Matching and Program Recommendations
By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to:

• review and analyze your health-related information
• determine your potential eligibility for diabetes-related products, services, and programs
• generate personalized recommendations based on your submitted information

The matching process begins immediately upon submission of your information.

3. Consent to Share Sensitive Health Data with Third Parties
By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to disclose your health-related information to third-party organizations for purposes of:

• evaluating eligibility
• facilitating referrals
• supporting enrollment
• connecting you with relevant healthcare-related products, services, or programs

Third-party recipients may include:

• healthcare providers
• telehealth services
• diabetes management programs
• medical device providers
• pharmacies
• pharmaceutical companies
• wellness and coaching organizations
• healthcare support services
• nutrition counseling
• clinical trial organizations or affiliates tasked with clinical trial patient enrollment

These organizations may contact you directly regarding products, programs, or services.

4. Compensation Disclosure
You understand and acknowledge that:

• Diabetes Advocates may receive compensation, referral fees, lead generation fees, or other remuneration in connection with matching you to third-party programs, products, or services
• such compensation may be tied to referrals, enrollments, or participation in third-party offerings

5. Sale of Personal Data Disclosure
You understand that some disclosures of your personal data may constitute a sale of personal data under applicable state law if monetary or other valuable consideration is exchanged. Where applicable, you retain the right to opt out of future sales of your personal data as permitted by law. Important State Exception:
Residents of Maryland may be entitled to additional restrictions regarding the sale of sensitive personal data under Maryland law.

6. Your Privacy Rights
Depending on your state of residence, you may have the right to:

• confirm whether your personal data is being processed
• access your personal data
• correct inaccuracies
• request deletion
• obtain a portable copy of your personal data
• opt out of the sale of personal data
• opt out of targeted advertising
• opt out of certain profiling activities

To exercise your rights, contact:
[email protected]

7. Revocation of Consent
You may revoke this Consent at any time by contacting:
[email protected] Revocation will apply prospectively and will not affect processing or disclosures already made in reliance on your Consent.

8. Data Retention
This Consent remains effective until:

• revoked by you
• account deletion
• or until your information is no longer needed for the purposes described above

9. Redisclosure Notice
You understand that once your health-related information is disclosed to a third party, it may no longer be protected by the same privacy obligations that apply to Diabetes Advocates and may be subject to redisclosure by the recipient.

10. Acknowledgment and Electronic Signature
By clicking “SHOW ME WHAT I QUALIFY FOR”, you acknowledge that:

• you have read and understand this Consent
• you voluntarily consent to the processing of your sensitive personal data
• you authorize disclosure of your health-related information as described above
• you understand that Diabetes Advocates may receive compensation in connection with these disclosures
• your click constitutes your electronic signature and express written consent for these uses and disclosures

Washington Consumer Health Data Notice (MHMD)

IMPORTANT NOTICE FOR WASHINGTON RESIDENTS By clicking “SHOW ME WHAT I QUALIFY FOR”, you request personalized health-related matching results and authorize the use of your consumer health data. You expressly authorize Diabetes Advocates to collect, use, analyze, and process your consumer health data including diabetes status, treatment information, and related health inputs to generate personalized eligibility results and recommendations. You authorize Diabetes Advocates to determine eligibility for third-party programs including healthcare providers, diabetes management programs, device programs, pharmacies, digital health services, wellness programs, and related offerings. You understand Diabetes Advocates may disclose relevant consumer health data to third-party partners and may receive compensation, which may constitute sale or sharing under Washington law. You may withdraw consent at any time by contacting [email protected]

California Consumer Medical Information Authorization

Notice for California Residents. By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to collect, use, disclose, and transfer your medical information including diagnosis, treatment history, therapies, device usage, health goals, related conditions, and demographic/contact information. This information may be used to evaluate eligibility for diabetes-related products, services, educational resources, providers, telehealth services, pharmacies, device providers, wellness programs, and healthcare-related organizations. You authorize disclosure to third parties for referrals, enrollment, outreach, and matching services. You understand Diabetes Advocates may receive compensation in connection with disclosures. Certain disclosures may constitute sale, transfer, or commercial use of medical information to the extent permitted by law. You may revoke authorization at any time by contacting [email protected] This authorization expires one (1) year from authorization date unless revoked earlier.

Notice for Texas Residents

By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to collect, use, disclose, and electronically transmit your health information. This includes diabetes diagnosis/status, treatment history, medication information, glucose monitoring information, care needs, related health conditions, and demographic/contact information. You authorize Diabetes Advocates to analyze such information to match you with healthcare providers, telehealth programs, diabetes programs, device providers, pharmacies, manufacturers, support programs, and related services. You authorize disclosure and electronic transmission of health information to third parties for eligibility verification, referrals, enrollment support, and outreach. You understand Diabetes Advocates may receive compensation and certain disclosures may constitute sale of health information under applicable law. You may revoke by contacting [email protected] Authorization remains valid until revoked, deletion request, or three (3) years.

Minnesota Consumer Health Records Authorization

Notice for Minnesota Residents. By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to collect, use, disclose, and electronically transfer your health records and related health information. This includes diabetes diagnosis/status, treatment history, medications, device usage, health goals, related conditions, and demographic/contact information. You authorize Diabetes Advocates to analyze records to match you with third-party diabetes-related programs, providers, telehealth services, pharmacies, manufacturers, wellness programs, and healthcare services. You authorize release and disclosure of records for referrals, enrollment, outreach, and eligibility matching. You understand Diabetes Advocates may receive compensation in connection with disclosures. You may revoke by contacting [email protected] Unless revoked earlier, authorization expires one (1) year from authorization date.

Nevada Consumer Health Data Authorization

Notice for Nevada Residents

By clicking “SHOW ME WHAT I QUALIFY FOR”, you are requesting personalized diabetes-related matching results and authorizing Diabetes Advocates to collect and use your consumer health data as described below. Your click constitutes your electronic signature, express written authorization, and affirmative acceptance of this Authorization.

1. Authorization to Collect and Use Consumer Health Data
By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to collect and use the consumer health data you provide, including:

• diabetes diagnosis or status
• treatment history
• medication and therapy information
• glucose monitoring information or device usage
• diabetes-related care goals and preferences
• related health conditions or risk factors
• contact and demographic information associated with your health data

This information will be used to evaluate your eligibility for diabetes-related programs, products, services, and educational resources. This processing begins immediately upon submission of your information.

2. Authorization for Matching to Third-Party Programs and Services
By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to analyze your consumer health data to determine whether you may qualify for third-party diabetes-related products, programs, and services, including:

• healthcare providers
• telehealth programs
• diabetes management programs
• medical device companies
• pharmacies
• pharmaceutical manufacturers
• coaching and wellness services
• other healthcare-related service providers relevant to diabetes care

The matching process begins immediately upon submission.

3. Authorization to Share Consumer Health Data
By clicking “SHOW ME WHAT I QUALIFY FOR”, you authorize Diabetes Advocates to share your consumer health data with third-party organizations for purposes of:

• determining eligibility
• facilitating referrals
• supporting enrollment
• connecting you to diabetes-related programs, products, or services
• enabling outreach regarding available offerings

These organizations may contact you directly regarding their programs, products, or services.

4. Compensation Disclosure
You understand and acknowledge that:

• Diabetes Advocates may receive compensation, referral fees, lead generation fees, or other remuneration in connection with matching you to third-party programs, products, or services
• such compensation may be based on referrals, introductions, enrollments, or participation with a third-party partner

Separate Authorization for Sale of Consumer Health Data (if applicable)

Important Nevada Notice:
Nevada law provides that your access to goods or services cannot be conditioned on your agreement to the sale of your consumer health data.

If Diabetes Advocates sells your consumer health data (meaning disclosure in exchange for monetary or other valuable consideration), your separate written authorization will be obtained before any such sale occurs.

Any such authorization will separately identify:

• the specific consumer health data to be sold
• the purchaser receiving the data
• the purpose of the sale
• how the purchaser will use the data
• your right to revoke authorization

5. Voluntary Authorization
You understand that:

• this authorization is voluntary
• you are not required to authorize the sale of your consumer health data to receive services
• if you do not authorize collection and sharing necessary for matching, we may not be able to provide personalized eligibility results

6. Right to Revoke
You may revoke this Authorization at any time by contacting:
[email protected]

Revocation will not affect disclosures already made in reliance on this Authorization.

7. Expiration
This Authorization remains valid until the earliest of:

• your written revocation
• account deletion
• one (1) year from the date of authorization

Nevada law limits sale authorizations to one year.

8. Redisclosure Notice
You understand that once your consumer health data is disclosed to a third party, it may no longer be protected by Nevada consumer health data privacy laws and may be subject to redisclosure by the recipient.

9. Acknowledgment and Electronic Signature
By clicking “SHOW ME WHAT I QUALIFY FOR”, you acknowledge that:

• you have read and understand this Authorization
• you voluntarily authorize the collection, use, and sharing of your consumer health data as described above
• you understand that Diabetes Advocates may receive compensation in connection with these disclosures
• your click constitutes your electronic signature and written authorization for these uses and disclosures