You are about to share medical data from {system_name} with {app_name}.

{app_name} would like to access and store personal medical information including:

Personal details like your name, address, phone number, email, and date of birth

Information about your insurance plans such as coverage type and member ID

History of your previous medical procedures

Description of your medical conditions as recorded by a clinician

Your medication history

Your vaccinations or immunizations history

List of providers and organizations involved in your care delivery

Explanation of benefits, including insurance payments made on your behalf and the amount you paid or owe for various healthcare services

This information shared may include or may infer certain sensitive information such as sensitive diagnosis codes, mental health status, pregnancy information, Abortion, AIDS/ARC, Alcohol and substance abuse, Behavioral health, Domestic violence, Genetic testing, HIV, Physical abuse, Reproductive health, or Sexually transmitted infections. You have the right to share your health information with this application or website, but there may be risks.

Once this entity ({app_name}) has accessed your data, it may no longer be protected by federal and state privacy laws such as HIPAA, and {system_name} is no longer responsible for the privacy and security of your data. Be sure to review this application or website’s Privacy Policy and Terms and Conditions to fully understand how they will handle your data.