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HIPAA Authorization

MeYou Health is dedicated to giving you the tools you need to improve your health while protecting your privacy. Therefore, we are asking for your permission (authorization) to allow Blue Shield of California to disclose certain information about you to MeYou Health. By providing this information to MeYou Health, you will be able to use our services and the benefits offered by your employer or health plan more effectively. With this information, MeYou Health can help you achieve your goals.

However, MeYou Health wants to make sure that you understand what we are asking you to agree to and your legal rights with respect to your information. We urge you to read this document carefully.

Signing this authorization is voluntary. If you choose not to sign this authorization, your employer or health plan will not reduce its payment for services or your benefits, limit your ability to obtain medical care, or limit future enrollment. However, if you choose not to sign this authorization, you may not be able to receive some of the benefits MeYou Health offers.

The “Protected Health Information” (also known as “PHI”) that this authorization allows Blue Shield of California to disclose includes your full name, gender, date of birth, group and participant identifier, mailing address, industry code, and activities related to incentive rewards. However, this authorization does not allow Blue Shield of California to disclose any other information contained in your health records, treatment records, diagnostic records, clinical records, or any other medical information.

It is important to understand that once Blue Shield of California discloses Protected Health Information about you to MeYou Health, it may no longer be protected by the HIPAA Privacy Rule (Title 45, part 164 of the Code of Federal Regulations). However, your information will be protected under the terms of MeYou Health’s Privacy Policy and Terms of Use. In addition, the Federal Trade Commission (“FTC”) and, in varying degrees, state law, also provide protections for the collection, use and disclosure of your personal information.

MeYou Health employs a number of approaches to protecting your information. In some limited circumstances, MeYou Health may disclose your information to others, but MeYou Health will always ask your permission before disclosing your information to anyone else. For a full description of how MeYou Health may use, hold, or disclose your information, please visit MeYou Health’s Privacy Policy and Terms of Use.

Federal law also gives you the right to inspect or copy the PHI covered by this authorization. MeYou Health will send this authorization to Blue Shield of California on your behalf. MeYou Health will also email you a completed copy of this authorization, which you should keep for your records.

This authorization will remain in effect and allows Blue Shield of California to disclose your Protected Health Information to MeYou Health for seven (7) years. This authorization will expire automatically after seven (7) years, but you may revoke this authorization electronically at any time by adjusting the sponsorship settings in your MeYou Health account. You may also revoke this authorization in writing at any time by sending written notification to Blue Shield of California at Attn: Wellness Department, Blue Shield of California, 50 Beale Street, 22nd Floor, San Francisco, CA 94105. This notice will not apply to actions taken by Blue Shield of California prior to the date they receive a written request to revoke this authorization.

If you have any questions, complaints, or concerns about this authorization form, we strongly encourage you to contact Blue Shield of California or MeYou Health at MeYou Health 92201, 177 Huntington Ave #1700, Boston, MA 02115.

Please give us your permission.