PathPoint+ HIPAA Release

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO PATHPOINT+

I hereby authorize all of my current and future healthcare providers and treatment facilities, including but not limited to physicians, nurse practitioners, physician assistants, dietitians, behavioral health clinicians, therapists, hospitals, clinics, pharmacies, laboratories, imaging centers, and other healthcare professionals and facilities (collectively, “Healthcare Providers”), and my health plan(s), to disclose my medical records and health information, including records received from third parties, to PathPoint Health MTN, LLC and its employees, agents, contractors, coaches, advisors and other personnel for the purposes of operating and administering the PathPoint+ Program (the “Program”), including creating and maintaining my personal health record within the PathPoint app/portal and assessing and improving the quality and effectiveness of services provided through the Program. I understand that my medical records may include information regarding alcohol or drug abuse, reference to or results of HIV antibody (AIDS) testing, or mental status. 

I understand that I may refuse to sign or may revoke this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of the treatment I receive from my Healthcare Providers. However, my failure to sign the Authorization may affect the quality of services I am able to receive under the Program.

I understand that I may revoke this Authorization at any time by written notice to PathPoint at:

PathPoint Health MTN, LLC, 1 Burton Hills Blvd, Ste 300E, Nashville, TN 37205, Attn: Legal; email: legal@pathpointhealth.com

Revocation is effective when logged by PathPoint and does not affect prior uses/disclosures made in reliance on this Authorization.

I understand that information disclosed under this Authorization may be subject to redisclosure by the recipient and not protected by HIPAA once redisclosed, except as otherwise required by law.

This Authorization expires when my enrollment in the PathPoint+ Program terminates.

Revised: January 13, 2026