HEALTH INFORMATION RELEASE AUTHORIZATION
and Acknowledgement of Program Terms and Conditions
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
As part of the ‘FREE Sheer White! Take Home Kit’ promotion, CAO Group, Inc. (“CAO") who is the manufacturer of the Sheer White! Tooth Whitening Strips (“Product”), offers as part of this promotion the opportunity for you, the patient, to receive one free Take Home Kit of the Product. This promotion involves the participation of a dental office or clinic of your choice. This can be the existing office to which you already visit for dental check-ups and treatments, or may be a different office that you designate.
Use and Disclosure of Your Information
In order to inform the designated office that you have selected their office as the site where you will pick up your free Take Home Kit, it is necessary for CAO to provide your name to this office so they can expect your arrival. An example of such a communication may be an email sent from CAO to the dental office with contents to the effect of:
“Dear <Dental Office>,
This is to inform you that an individual by the name of <Your Name> has selected your office as the pick-up site for a free Sheer White! Tooth Whitening Strips Take Home kit. This free kit will shipped to your office directly from CAO Group at no cost to you. This individual may or may not already be a patient of your office. The individual will be notified when shipping records show that the free kit has arrived at your office. Please note that the kit is labeled with the individual’s name on it. We ask that you please keep the free kit refrigerated until pick-up, consistent with product labeling. Please feel free to contact CAO with any questions regarding this free sample, the ‘FREE Sheer White! Take Home Kit’ promotion, offering Sheer White in your practice, or other CAO Group products.”
Disclosure of your name will be limited to this communication to the designated dental office as described within this authorization. Your name will not be disclosed to any other entities, except as required under the Health Insurance Portability and Accountability Act (“HIPAA”), which includes disclosure to federal personnel in their duties under HIPAA, disclosure to law enforcement personnel, disclosure under a court order, and other disclosures provided for in the Act. Any other disclosure outside the terms of this authorization will require a separate written authorization in writing from you. CAO will not request any protected health information from the dental office. CAO may request the dental office to confirm whether or not you are currently a patient of that office. You will not be obligated to become or continue to be a patient at the dental office you designate.
You have the right to restrict use of your information or revoke this authorization of use at any time by providing such request in writing to email@example.com or to: CAO Group, Inc., Attn: HIPAA Compliance Officer, 4628 West Skyhawk Drive, West Jordan, UT 84084. Further, you have the right at any time to inspect and copy your information. You also have the right to receive a paper copy of this authorization by making such a request at the email or address just indicated. You may lodge a complaint at the indicated address if you feel your information has been used contrary to this authorization, where such use may have originated with this information you are now providing to CAO. Alternatively, you may lodge such a complaint directly with the office of the Secretary of Health and Human Services.
CAO Group’s Obligations
CAO shall limit access to this information to those employees and personnel of CAO Group, including its directly controlled affiliate entities, sufficient for perfoming the actions of the promotion as described herein. CAO is required by law to maintain the privacy of protected health information, to provide individuals with notice of its legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. CAO shall abide by the terms of any such notice then in effect. CAO will commit to applying any change in a privacy practice that is described in the notice applied to your information that CAO receives from you prior to issuing a revision notice, in accordance with HIPAA regulations. CAO reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains. Such a statement must also describe how it will provide individuals with a revised notice.
Promotion Terms and Conditions
This promotion is only available in the United States and CAO retains the right to end this promotion at anytime, and to suspend any request due to incomplete verification or suspected acts of fraud or deception. The promotion is limited to one FREE Sheer White! Take-Home kit per person. Failure to sign and submit this authorization, or the cancellation of this authorization, may result in a halt of processing this request until this agreement is completed and signed.
Who can receive my health information:
By signing you are giving authorization for CAO Group, Inc. to be able to discuss the information on this form with the person(s)/organization(s) indicated on this form. You understand that CAO Group, Inc. or the person(s)/organization(s) you have listed on the form may not be covered by state/federal rules governing privacy and security of data and may be permitted to share the information that is provided to them.
Duration of Authorization:
This agreement will go into effect on the date that the form is submitted and will be limited to a 90 day period from the date of your signature. After this period, CAO will have no right or ability to discuss the information provided under this authorization except as required under HIPAA regulations.
In order for CAO Group. Inc to disclose information to the person(s)/organization(s) listed, a copy of this agreement to the individual requesting this offer is implied. The copy of the completed authorization form will be communicated in the email confirmation provided once this form is agreed upon and submitted.
Acknowledgement of Understanding:
By signing this release you acknowledge that you understand the nature and extent of the information being disclosed and the potential risks associated with such disclosure. You further understand that once protected health information is disclosed, it may no longer be protected by federal privacy regulations.
By adding my electronic signature and agreeing to the terms and conditions below I am agreeing to allow CAO Group, Inc to use my information in marketing through CAO Group, inc. or any other companies related to CAO Group, Inc. CAO Group, Inc. will not sell or distribute any information to any third parties. By adding your name to this field and agreeing to the terms and conditions you are consenting that this will represent your electronic signature.