BCHHC

Disclaimer: I understand that I am voluntarily submitting personal information that relates to my health status. This information is not intended to be used for providing healthcare services or for the payment for any past, present or future healthcare services. I understand that by voluntarily submitting the data electronically, the data may be accessed, used or disclosed by a third-party. By submitting this data, I waive any rights to privacy, security or confidentiality of such data provided by state or federal laws.

Authorization: Through my electronic submission, I hereby submit and authorize the release of the personally identifiable health information requested by the electronic surveys and data contained within the A.D.A.M.'s SmartSites™ "Program", to A.D.A.M. Inc. I hereby authorize the disclosure of my individually identifiable health information for the purposes of performing a health assessment and for the purposes of Program. The personal health information may be used or disclosed by Program and its administrators for business management and operations. I understand that A.D.A.M. Inc. is not a healthcare provider and this Program will not condition my ability to obtain treatment, payment for healthcare services or eligibility for enrollment for health benefits. I also acknowledge and agree that by submitting such information I understand that I am waiving any confidentiality, privacy or security protections provided by State and federal laws and the information may be subject to re-disclosure. I also understand that I may revoke this authorization by submitting a written revocation statement to HIPAA@adamcorp.com to cease the further use or disclosure of the personally identifiable health information. A.D.A.M. Inc. and its users may rely upon this authorization to use and disclose the submitted information prior to receipt of the written revocation notice. This authorization shall be effective on the date the information is submitted and valid for the term that this Program is available for use or for the time period permitted by state law, whichever is longer.