Visit Participation & PHI Authorization

This authorization permits healthcare providers and clinical entities to disclose relevant information to ShadowNurse during and after medical visits. It allows ShadowNurse to participate remotely in appointments to assist patients in understanding care, preparing for visits, and following up on treatment. The authorization remains effective indefinitely unless revoked in writing, and revocation does not affect previously disclosed information.

Purpose

This authorization allows ShadowNurse, Inc. to assist during your medical care by participating in appointments, receiving protected health information related to those appointments, and coordinating follow-up support at your direction.

Authorization to Participate in Medical Visits

ShadowNurse, Inc., including nurses, care navigators, and administrative staff, is authorized for remote participation in your medical visits. This covers:

• Telephone, video, or audio-only presence during in-person or telehealth appointments
• You choose when to involve a ShadowNurse representative
• The representative may hear and discuss information shared during clinical encounters

Authorization to Receive and Disclose Protected Health Information

Healthcare providers, health plans, and clinical entities may disclose the following to ShadowNurse:

• Medical history
• Medications
• Diagnoses
• Visit notes
• Eligibility information
• Scheduling details

Permitted Uses

• Understand medical care
• Prepare for and follow up on appointments
• Coordinate recommended services
• Support ongoing care navigation
• Disclose information back to healthcare providers when necessary

Clinical Entities Referenced

OpenLoop Healthcare Partners, PC, and any future medical groups that may provide clinical services coordinated through ShadowNurse.

Description of Information to Be Disclosed

This covers medical and administrative information relevant to your care, including:

• Written, verbal, and electronic communications
• Diagnoses and treatment plans
• Medications and lab/imaging results
• Visit notes and after-visit summaries
• Referrals and care plans
• Scheduling information
• Insurance and eligibility details
• Records needed for care coordination

Voluntary Nature of Authorization

Signing this authorization is voluntary. Your decision to sign or not sign will not affect your ability to receive medical care, obtain insurance benefits, or use ShadowNurse’s services, except to the extent that ShadowNurse may be unable to assist you during medical visits without this authorization.

Right to Revoke

You may revoke this authorization at any time by notifying ShadowNurse in writing at: hello+HIPAA@shadownurse.com

Revocation does not affect information already disclosed or relied upon before revocation was received.

Expiration

This authorization does not expire unless you revoke it in writing.

Redisclosure

You understand that information disclosed to ShadowNurse may no longer be protected by HIPAA privacy rules if ShadowNurse is not acting as a HIPAA covered entity or business associate. ShadowNurse will safeguard information according to its Privacy Policy.

Acknowledgment

Your agreement to this authorization is documented through your electronic signature when you check the required authorization box within the ShadowNurse intake process. That electronic acknowledgment constitutes your signature for this authorization.

Contact

For questions about this authorization or to submit a revocation:

• Email: hello+HIPAA@shadownurse.com
• Phone: 505-535-5255
• Text: 505-535-5255