HIPAA Consents

This is a HIPAA authorization document, for release of medical records to Trellis Health Systems, Inc., on your behalf as part of a private beta program. Trellis Health may disclose personal health information (PHI) to our physician partners for care delivery, as you authorize; but will never disclose, decrypt or share your data in any other way. Your data remains secure and encrypted on our services, with banking level security.

THIS LIMITED MEDICAL RECORD REQUEST FORM IS USED ONLY FOR TRELLIS HEALTH ALPHA PROGRAM AND IS NOT VALID FOR ANY OTHER USE.

You are participating in the following program with Trellis Health.

During the course of this program TRELLIS HEALTH ALPHA PROGRAM Trellis Health will have access to your medical records. This Limited Medical Record Request will give Trellis Health only limited rights to your Medical Records. You may have other rights under HIPAA regarding your medical records not related to this program and limited release form. You can contact us with any other questions or requests that you may have at:

hello@jointrellishealth.com.

For purposes of this particular program TRELLIS HEALTH ALPHA PROGRAM, Trellis Health is limiting the participants and medical requests only to those:

Participants making requests on behalf of themselves.
Participants not requesting the medical records be sent to another entity.
Participants not limiting the type or kind of PHI shared with Trellis Health.
Participants only requesting the records for this particular program TRELLIS HEALTH ALPHA PROGRAM

THIS LIMITED MEDICAL RECORD REQUEST FORM IS USED ONLY FOR TRELLIS HEALTH ALPHA PROGRAM AND IS NOT VALID FOR ANY OTHER USE.

Trellis Health Systems, Inc. 92 Lenora Street, #150 Seattle WA 98121, United States (“Trellis Health” ).

Trellis Health provides a service that is a cloud-based platform for requesting, retrieving, and contributing patient information from health data sharing networks and other third-parties. Trellis Health organizes and provides smart interaction software tools on a user’s own health data to allow users to track, understand and communicate their health. In providing this service Trellis Health may have access to or be able to grant access to an individual's Protected Health Information ("PHI"). Trellis Health practices least privileges access to data in all our systems by Trellis Health employees. Trellis Health data platform is secured to banking level security, and will only share PHI as authorized by a user, with their healthcare providers for the purpose of care-coordination.

The purpose of this HIPAA release form is to confirm the identity of the requestor, through the onboarding identity verification process within the Trellis Health application and to allow Trellis Health to fulfill a records request using its platform to receive PHI about the individual making the request, in order to populate that information in the users’ Trellis Health account.

THIS LIMITED MEDICAL RECORD REQUEST FORM IS USED ONLY FOR TRELLIS HEALTH ALPHA PROGRAM AND IS NOT VALID FOR ANY OTHER USE.

You are participating in the following program with Trellis Health.

hello@jointrellishealth.com.

For purposes of this particular program TRELLIS HEALTH ALPHA PROGRAM, Trellis Health is limiting the participants and medical requests only to those:

Participants making requests on behalf of themselves.
Participants not requesting the medical records be sent to another entity.
Participants not limiting the type or kind of PHI shared with Trellis Health.
Participants only requesting the records for this particular program TRELLIS HEALTH ALPHA PROGRAM

THIS LIMITED MEDICAL RECORD REQUEST FORM IS USED ONLY FOR TRELLIS HEALTH ALPHA PROGRAM AND IS NOT VALID FOR ANY OTHER USE.

Trellis Health Systems, Inc. 92 Lenora Street, #150 Seattle WA 98121, United States (“Trellis Health” ).

Section I

The following personal details are captured and verified during Trellis Health onboarding within the application:

Full Name:

Address:

Date of Birth:

By confirming your personal information on there confirmation page and checking the box for HIPAA authorization, you give permission for Trellis Health to use your information to request, retrieve, and receive the PHI described in Section Il of this document.

The following personal details are captured and verified during Trellis Health onboarding within the application:

Full Name:
Address:
Date of Birth:

Section II

Health Information permitted to be shared.

You give Trellis Health permission to request, retrieve, and receive your PHI. Trellis Health may obtain part or all of your complete health records, on your behalf, including but not limited to: diagnoses, lab test results, treatment, and billing records for all conditions.

Health Information permitted to be shared.

You give Trellis Health permission to request, retrieve, and receive your PHI. Trellis Health may obtain part or all of your complete health records, including but not limited to: diagnoses, lab test results, treatment, and billing records for all conditions.

Section III

Name of Entity to Release my PHI.

By checking this HIPAA authorization box, you are requesting your PHI be released to:

Trellis Health Systems, Inc. 92 Lenora Street, #150 Seattle WA, United States (“Trellis “Health).

Name of Entity to Release my PHI.

By checking this HIPAA authorization box, you are requesting your PHI be released to:

Trellis Health Systems, Inc.
92 Lenora Street, #150 Seattle WA, United States (“Trellis “Health).

Section IV

Revocation.

I understand that Trellis Health may not be covered by state/federal rules governing the privacy and security of data and once released to Trellis health, the information may no longer be protected by HIPAA. I understand that I am permitted to revoke this authorization to share my PHI by submitting a request in writing. I understand that in the event my information has already been shared with a user’s provider by the time my authorization is revoked, it may be too late to cancel permission to share my PHI. Trellis Health will delete and archive all PHI in our systems apon request to revoke authorization. Unless revoked, this authorization will remain in effect until the expiration or termination as permitted in this Agreement or as listed below.

Revocation.

Section V

Duration of Authorization

This authorization is valid for the duration listed below:

1. From this date of checkbox and onboarding completion within the Trellis Health mobile application, until 1 year after this date (period of the TRELLIS HEALTH ALPHA PROGRAM). Duration of this authorization is automatically renewed in annual increments as long as you are an active, subscribed user of the Trellis Health application.

Duration of Authorization

This authorization is valid for the duration listed below:

Section VI

Reason for Disclosure

Personal Records Request to participate in the Trellis Health Alpha Program, and care-coordination health records request to share information as needed, and as authorized, with healthcare providers involved in your healthcare. These providers may be providers ie midwives that are contracted with Trellis Health, or your primary physician handling pregnancy care.

Reason for Disclosure

Section VII

Signature

By checking the HIPAA release box and clicking “Confirm” within the Trellis Health application this will act as a digital signature for the individual verified through the Trellis Health application. This will be date stamped and serve as the date of your authorization.

Signature