DATA SHARING POLICY

Pursuant Health is committed to protecting your privacy. This Data Sharing Policy applies to personally identifiable information that is collected on pursuanthealth.com and through our Pursuant Health Kiosk.

I. INFORMATION COLLECTION AND DATA SHARING POLICY DISCLAIMER

Authorization to Use or Disclose Information for Lead Generation

Pursuant Health Kiosk Consumer (Consumer) hereby authorizes Pursuant Health to use or disclose the Protected Health Information (PHI) listed below, collected by Pursuant Health through registration or as part of a Pursuant Health Kiosk service request:

•      Full Name (Electronic Signature)
•      Email Address
•      Phone Number
•      Zip Code
•      Date of Birth

Pursuant Health seeks to disclose this Protected Health Information to insurance agencies for the generation of potential leads where partnering insurance agencies can contact the consumer to promote their products and services.

Consumer hereby acknowledges that he/she understands that treatment, payment, enrollment in any health plan, or eligibility for benefits is not conditioned on his/her signing of this Authorization.

Consumer is entitled to a copy of this agreement and the information to be used or disclosed. The agreement is available at pursuanthealth.com. The information used or disclosed will be available via a request form on the previously mentioned web address. Consumer may refuse to sign this Authorization if he/she so chooses.

This agreement shall be effective on the date of Pursuant Health Kiosk visit and shall remain valid for one year unless a State Law requires otherwise.

At all times, Consumer retains the right to revoke this Authorization. Such revocation must be submitted to Pursuant Health in writing. The revocation shall be effective except to the extent that Pursuant Health has already used or disclosed information in reliance on the Authorization. Consumer may revoke this Authorization by sending a written notice to:

        Pursuant Health
        780 Johnson Ferry Road, Suite 625
        Atlanta, GA 30342

Consumer has been informed and understands that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient of such information, and, at that point, the information may no longer be protected under the terms of this agreement.

I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY OF THIS AGREEMENT [OR I UNDERSTAND I AM ENTITLED TO A COPY OF THIS AGREEMENT]. I AM THE CONSUMER OR AM AUTHORIZED TO ACT ON BEHALF OF THE CONSUMER TO SIGN THIS FORM VERIFYING AUTHORIZATION FOR THE USE OR DISCLOSURE OF THE PROTECTED HEALTH INFORMATION UNDER THE ABOVE STATED TERMS.

Authorization to Use or Disclose Information for Member Engagement

Pursuant Health Kiosk Consumer (Consumer) hereby authorizes Pursuant Health to use or disclose the Protected Health Information (PHI) listed below, collected by Pursuant Health through registration or as part of the Consumer’s request to submit health assessment information to the Consumer’s insurance agency:

•      First Name
•      Last Name
•      Date of Birth
•      Gender
•      Health Insurance Agency Member ID
•      Health Assessment Information (Blood Pressure, BMI, etc.)
•      Email
•      Phone Number
•      Address

Pursuant Health seeks to disclose this Protected Health Information to the Consumer’s insurance provider as a service to and on behalf of the insurance provider for the purpose of providing members with eligibility for discounts and/or equivalent benefits per agreement and communication between the Consumer and his/her insurance provider.

Consumer hereby acknowledges that he/she understands that treatment, payment, enrollment in any health plan, or eligibility for benefits is not conditioned on his/her signing of this Authorization. Consumer is entitled to a copy of this agreement and the information to be used or disclosed. The agreement is available at pursuanthealth.com. The information used or disclosed will be available via a request form on the previously mentioned web address.

Consumer may refuse to sign this Authorization if he/she so chooses.

This agreement shall be effective on the date of Pursuant Health Kiosk visit and shall remain valid for one year unless a State Law requires otherwise.

At all times, Consumer retains the right to revoke this Authorization. Such revocation must be submitted to Pursuant Health in writing. The revocation shall be effective except to the extent that Pursuant Health has already used or disclosed information in reliance on the Authorization.

Consumer may revoke this Authorization by sending a written notice to:

        Pursuant Health
        780 Johnson Ferry Road, Suite 625
        Atlanta, GA 30342

Consumer has been informed and understands that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient of such information, and, at that point, the information may no longer be protected under the terms of this agreement.

I HAVE READ AND UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY OF THIS AGREEMENT [OR I UNDERSTAND I AM ENTITLED TO A COPY OF THIS AGREEMENT]. I AM THE CONSUMER OR AM AUTHORIZED TO ACT ON BEHALF OF THE CONSUMER TO SIGN THIS FORM VERIFYING AUTHORIZATION FOR THE USE OR DISCLOSURE OF THE PROTECTED HEALTH INFORMATION UNDER THE ABOVE STATED TERMS.

 

II. DATA SHARED REQUESTS

In order to receive the information that we have shared on your behalf, please email Pursuant Health at info@pursuanthealth.com. Please include as much information as necessary for us to provide you with the exceptional support you are requesting. Items that you can include to facilitate a much faster response are (Name, Location of Kiosk, Day of Visit, etc.).

 

III. EFFECTIVE DATE

This Data Sharing Policy is effective as of July 19, 2013.