Legal

Authorization

I authorize the use and disclosure of my Personal Information, for the Purposes identified below, by the following:

• My long-term care insurance company (“Insurance Company”)

• My nursing home, assisted living facility, long-term care facility, home care provider or other similar businesses that have provided treatment or other services to me or on my behalf (“Provider”) 

• CareScout, LLC and its service providers (“CareScout”) 

I authorize my Insurance Company and Provider to use my Personal Information for the Purposes numbered one (1) through two (2) and to disclose this Personal Information for those Purposes to CareScout.  I authorize CareScout to use and disclose my Personal Information for Purposes numbered one (1) through three (3).  

Personal Information

Personal Information may include my health information, my demographic information, and any information that my Insurance Company has obtained about me in connection with an insurance application, insurance policy, or claim(s) for benefits; any information, including health and demographic information, that my Provider has obtained about me in connection with the services provided by the Provider; and any information CareScout has obtained about me, including health and demographic information, in connection with the services, including services  for any insurance policy claim eligibility assessments, provided by CareScout.  

Purposes 

1. I understand and acknowledge that my Personal Information may be used and disclosed, electronically or otherwise, by my Insurance Company and my Provider under this authorization so that CareScout may provide me offers and services through its platform and to help in the application of any applicable negotiated pricing to the services I have received from my Provider.

2. I understand and acknowledge that my Personal Information may be used and disclosed, electronically or otherwise, by my Insurance Company and Provider to CareScout to allow CareScout to:

        a. validate my membership and status with CareScout as an eligible policyholder and member of the CareScout platform; and

        b. assist in the confirmation of the accurate application of any applicable negotiated pricing to the services I have received from my Provider. 

3. I understand and acknowledge that my Personal Information may be used by CareScout to perform the services I have requested as well as to facilitate the CareScout services.  I further understand and acknowledge that my Personal Information may be disclosed, electronically or otherwise, by CareScout in order for CareScout to provide me with the services.  Such disclosures include disclosures made to service providers that perform services on behalf of CareScout, to third party tracking mechanisms such as cookies, web beacons, and pixels, and to third parties for the purpose of marketing products and services to me.  CareScout will also make disclosures of my Personal Information as required by legal or regulatory authority or as otherwise authorized by me.

Statements of Understanding, Declaration and Signature(s) 

• This authorization shall remain in force from the date it is signed for as long as I am a customer of CareScout, unless limited by my resident state. 

• I understand that I may revoke this authorization at any time in writing.  You may use the Contact Us feature on CareScout.com to send your revocation by writing in the free text field that you wish to revoke your HIPAA Authorization.   

• I understand that a revocation of this authorization is not effective as to anyone who has relied on this authorization prior to the date CareScout receives and processes the revocation.

• I understand that this authorization is voluntary and that my application for insurance or insurance claims with my Insurance Company and the treatment and care provided to me by my Provider will not be affected if I do not sign this authorization. 

• I understand that any Personal Information disclosed pursuant to this authorization may be re-disclosed, to the extent allowable under federal and state law, and may no longer be covered by certain federal or state rules governing privacy and confidentiality of health information.  Any Personal Information disclosed to CareScout pursuant to this authorization is then under the control of CareScout.  CareScout has responsibility for the privacy of the disclosed Personal Information in accordance with applicable laws and CareScout’s privacy policy.

• The Insurance Company and the Provider may not condition treatment, payment, enrollment or eligibility for benefits on the signature of this Authorization.

• A copy of this Authorization will be considered as valid as the original.  

• I have received a copy of this authorization.