Information Disclosure Authorization
By completing and submitting your registration and clicking below, you acknowledge and agree that:
1) Your registration and participation are voluntary, and that you may refuse this authorization to not
participate in the program.
2) You are voluntarily agreeing to allow the collection, use and disclosure of health information about you
As part of the program, QualityHealth will collect, use, and disclose certain information, including
you provide during registration, and information about the prescriptions you buy using your Prescription
Card (which may include information about: mental health, human immunodeficiency virus, acquired immune
deficiency syndrome, genetic testing, drug/alcohol diagnosis, treatment and/or referral) in order to
the program, evaluate the effectiveness of the program and marketing campaigns, and to communicate general
administrative information to you about membership. This information is typically protected by federal
regulations, but by authorizing its use and disclosure, it may not be protected by the same regulations.
QualityHealth will never sell your Protected Health Information to any third party for its own commercial
purposes, and, unless otherwise required by law, will only share Protected Health Information in
accordance with contracts where service providers agree to use the information as described in this
By signing this Authorization below, you understand: You are the individual whose information will be
and released, or that you are authorized to act on that individuals behalf,
You may revoke this Authorization in writing at any time.