Authorization for Use and Disclosure of Protected Health Information
By using the Heat Risk Assessment application, you consent to our collection, use, and disclosure of your protected health information (PHI) as described in this form.
Information to be Used or Disclosed
The protected health information that may be collected, used, and disclosed includes:
- Geographical location data
- Heat vulnerability indicators
- Health risk assessment data
- Medical conditions relevant to heat vulnerability
Purpose of Disclosure
Your information will be used to:
- Provide personalized heat risk assessments
- Generate health recommendations based on heat vulnerability
- Improve the accuracy of our prediction models
- Send emergency alerts when appropriate
Expiration
This authorization will remain in effect until you revoke it or until your account is inactive for 24 months.
Your Rights
You have the right to:
- Revoke this authorization at any time by contacting us
- Inspect and receive a copy of your PHI
- Request restrictions on certain uses and disclosures
- Receive an accounting of disclosures of your PHI