1. What I am authorizing

1. I authorize SurgiQuality and its affiliates, its employees and agents, to obtain my personal health information, including medical records and imaging studies from my healthcare providers and facilities, including without limitation radiology facilities.
2. I authorize all of my healthcare providers and facilities, including without limitation radiology facilities, to upload my personal health information directly into the SurgiQuality platform through a link sent by SurgiQuality and its affiliates, its employees and agents.
3. I authorize SurgiQuality and its affiliates, its employees and agents, to release to their network of surgeons, other healthcare providers and organizations my personal health information for diagnosis, treatment, claims payment, and health care services facilitated through the SurgiQuality marketplace platform and for the operation and administration of the SurgiQuality marketplace platform.

2. Re-disclosure notice

I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws, unless prohibited by certain more restrictive law, and with certain limited exceptions.

Further, if I am a resident of California, any person or organization to whom my personal health information is disclosed pursuant to this Authorization may not further use or disclose the personal health information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by applicable law.

3. Scope, term, and revocation

This Authorization is specific to the procedure named at signing. A separate Authorization is required for each procedure I bring to SurgiQuality — the authorization granted here does not extend to other procedures or other Cases.

This Authorization remains in effect for the duration of that procedure’s case (typically a few weeks while records are collected and opinions are delivered). I may revoke this Authorization at any time by providing written notice to:

SurgiQuality
15005 Shady Grove Road, Suite 350
Rockville, MD 20850

However, this Authorization may not be revoked to the extent SurgiQuality has taken action on this Authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this Authorization.

4. Voluntary nature

I further understand that this Authorization is voluntary and that I may refuse to agree to this Authorization. My refusal to agree will not affect my eligibility for benefits or enrollment or payment for or coverage of services unrelated to healthcare services offered outside of the SurgiQuality marketplace platform.

5. Age affirmation and personal representative

I affirm that I am at least eighteen (18) years of age and have the legal authority to consent to this Authorization.

If I am signing as the personal representative of the User (e.g., a parent of a minor, a court-appointed guardian, a holder of a healthcare power of attorney, or a spouse with a healthcare proxy), I will complete the personal representative information at signing and confirm my legal authority to consent on the User’s behalf.

6. Required information at signing

The signing form on /your-records/ captures the following. For preview purposes, the fields are shown below; you do not need to print or fill anything in advance.

Audit metadata captured automatically: IP address, device user agent, document version (hipaa-v1-2023-03-03), and exact timestamp of signing.