HIPAA Authorization

I understand that Nutricia North America and its third party contracted agents (“Nutricia”) is not a healthcare provider or a Covered Entity or Business Associate as defined by the Healthcare Insurance Portability and Accountability Act (“HIPAA”) and, as a result, information I enter into MyKetoPlanner will not be protected pursuant to the terms of HIPAA. I also understand that any and all personal information I enter into MyKetoPlanner and all other Nutricia Digital Properties is pursuant to Nutricia’s Terms of Use and will be used as set forth in Nutricia’s Privacy Policy. To the extent necessary for my use of Nutricia’s MyKetoPlanner, I authorize my healthcare providers to disclose to Nutricia medical information (“Health Information”) and records which pertain to the patient listed on this online registration form or me, necessary for use of the MyKetoPlanner tool. This Health Information may include patient medical history or treatment plan. I understand that once Health Information is disclosed it will no longer be protected by federal privacy law. I know I can refuse to sign this form. I may withdraw it at any time and for any reason. This won’t affect the start or continuing of my treatment. It will have no effect on the quality of my treatment. However, if I revoke (cancel) this authorization, I may no longer be eligible to use the MyKetoPlanner services offered by Nutricia. If I do not want Nutricia to continue to receive my Health Information, I can notify Nutricia that I want to cancel this registration and authorization by writing to Nutricia at 9900 Belward Campus Drive, Suite 100, Rockville, MD 20850. Such notice will be effective upon receipt by Nutricia, but will not change any actions that Nutricia or others took in reliance upon this authorization before the date that I cancelled this authorization.