In relation to my participation in the GLP-1 Weight Management Program (the "Program"), I authorize my licensed telehealth provider including, but not limited to, licensed providers providing me medical care affiliated with Beluga Health, P.A., or Cynergy Wellness, Inc. ("my Telehealth Provider"), to use and disclose my protected health information held by them, to me, my employer sponsoring this Program, eMed Population Health, Inc.
and its affiliates (“eMed”), and to lab services companies, third party telehealth proctoring service companies, and affiliated pharmacy benefits managers and pharmacies providing services to me under the Program (collectively, the "Parties").
I understand that I am authorizing my Telehealth Provider to use and disclose this information to: (1) me to provide me with my GLP-1 screening and weight loss services and other health care services; (2) my employer to administer the Program and provide benefits to me associated with the Program; (3) eMed to engage in marketing and to conduct health care operations, including conducting quality assessment and improvement activities, data aggregation, care coordination, population health activities, and other business and management activities; and (4) the weight loss medication manufacturer to conduct health care operations, including developing and improving its medication(s).
I understand that this authorization will expire in three (3) years unless I revoke it prior to that date.
I understand that I will receive no remuneration for the disclosure of my protected health information, and that the Parties will not receive remuneration for the disclosure of my protected health information pursuant to this authorization.
I understand that once the protected health information is disclosed pursuant to this authorization, it may be redisclosed and no longer protected by federal privacy regulations. However, California law may prohibit the Parties from making further disclosure of my protected health information that I have not approved in this form, unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.
I understand that I do not have to execute this authorization and that my refusal to execute it will not affect my ability to obtain treatment from the Parties, nor will it affect my eligibility to obtain payment for such health care. I may request a copy of this authorization. I have the legal capacity and authority to provide this authorization for myself and/or the minor for which I am providing this authorization under applicable federal and state laws, including the laws relating to the age of majority and parental/guardian consent.
I understand that I have the right to revoke this authorization at any time. To revoke this authorization, I may contact Privacy Officer, at eMed Population Health, Inc., at 990 Biscayne Boulevard, Suite 1501, Miami, Florida 33132. I understand that the revocation will not apply to information that has already been released in response to this authorization.
By clicking the Allow button below, you are signing this agreement electronically; you affirm that you understand the content of this authorization, you reached your decision free from pressure and coercion, and you authorize the release of your protected health information as indicated above. You understand that you are entitled to a copy of this signed Authorization.
Last updated: September 4, 2025