Minor’s Authorization to Disclose Protected Health Information (PHI)

Last modified: January, 2022

Under Federal and State privacy laws, Galileo, Inc. and Galilea Medical Group, P.A. (individually or collectively herein “Company”) is authorized to use or disclose your health information for payment, treatment and health care operations and as required by law. For uses and disclosures other than these purposes, your written authorization is required before sharing your health information. This includes sharing your health information with your parent or guardian when such information pertains to medical services you consent to on your own behalf to the extent permitted by state law (as opposed to services which your parent/guardian consents to on your behalf). This authorization allows you to authorize the Company to disclose to your parent/guardian your health information related to medical services you consent to on your own behalf to the extent permitted by state law. Unless otherwise indicated in writing, your authorization will be valid for purposes of responding to any medical records request submitted by your parent/guardian. It will automatically expire when you reach the age of eighteen (18) years, or if Company receives a written request from you at privacy@galileohealth.com revoking this authorization. Please review this document carefully and confirm through your Galileo account whether you authorize Galileo to disclose to your parent/guardian information about certain services which you may have a right to obtain confidentially under state law. 

AUTHORIZATION:

I understand that I may authorize, through this form, the sharing with my parent/guardian of any information related to the types of services which are permitted to be provided to me confidentially, to the extent that I consent on my own behalf to the provision of such services at the point of care.

I understand the following: (1) if the entity authorized to receive my health information is not a health plan, health care provider or other covered entity as described by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, the released information may no longer be protected by federal privacy laws, rules and regulations; (2) the information disclosed will only include mental health, substance (including alcohol) abuse, sexually transmitted disease/infection or HIV, pregnancy and reproductive health information for which I have consented to services on my own behalf and have a right to confidentiality under my state’s law if I specifically direct Company to release that information after reviewing this form; (3) I am not required to agree to this form, but if I do not agree to this form, it will not be considered valid, and no information will be released by Company to my parent/guardian regarding services which I have consented to on my own and have a right to confidentiality under my state’s law; (4) I may revoke this authorization at any time by notifying Company in writing; (5) if I do revoke this authorization, my revocation will have no effect on any actions Company took according to this authorization before Company received my revocation; and (6) it is my choice whether I agree to this form and whether or not I agree to this authorization will not limit my ability to access medical services through Galileo.

I understand that this authorization replaces any prior HIPAA authorization I have previously provided to the Company. I agree to this authorization and attest to my identity under penalty of perjury.