HIPAA Authorization and Letter of Authorization

Authorization for Release of Protected Health Information

Patient

Full name as entered in the app

Date of birth

As entered in the app

Authorizing person

The signer, and their relationship to the patient (self, parent, spouse, child, other)

Recipient

Lazarus LLC d/b/a Offload, and its authorized agents

Expires

24 months from signature unless revoked earlier in writing

1. Authorization. I authorize any health care provider, health plan, hospital, laboratory, pharmacy, billing office, collection agency acting for any of them, or clearinghouse that has provided services to or maintains records about the patient named above (each a “Discloser”) to disclose protected health information (“PHI”) about the patient to Lazarus LLC d/b/a Offload (“Offload”) and its authorized agents, by phone, fax, mail, patient portal, or secure electronic transfer.

2. Information covered. Billing statements and itemized bills; claims, remittances, and explanations of benefits; coverage, eligibility, prior-authorization, and medical-necessity determinations; appeal and grievance records; payment and financial-assistance records; and the minimum medical record information (such as dates of service, diagnosis and procedure codes, orders, and clinical notes) needed to negotiate a bill, dispute a charge, or appeal a denial. This may include information about mental health, substance use disorder treatment, HIV/AIDS status, reproductive health, and genetic information, but only to the extent it appears in the billing or claim records being negotiated or appealed. I understand that federally protected substance use disorder records (42 CFR Part 2) may be released under this authorization only for the purpose stated here and may not be further disclosed without my written consent except as permitted by that regulation.

3. Purpose. To allow Offload to review, negotiate, dispute, and appeal medical bills and insurance claims on the patient's behalf; to request itemized statements, records, and financial-assistance determinations; and to communicate with Disclosers, insurers, and billing offices for those purposes. This authorization is at my request and for my benefit.

4. Right to revoke. I may revoke this authorization at any time by emailing support@offload.help or by writing to Lazarus LLC, 4413 Indigo Ln, Murrells Inlet, SC 29576. Revocation takes effect when Offload receives it. It does not affect disclosures already made in reliance on this authorization, and it does not undo actions Offload has already taken.

5. Re-disclosure. I understand that once information is disclosed under this authorization it may be re-disclosed by the recipient and may no longer be protected by federal privacy rules. Offload contractually limits its staff and agents to the purpose in Section 3, stores the information in private encrypted storage, does not use it for marketing, and re-discloses it only to the Disclosers, insurers, and billing offices involved in the patient's bills and claims.

6. Conditions. No Discloser may condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization. Offload will provide the service only with this authorization, because it cannot obtain records without it. I am entitled to a copy of this signed authorization and can download it from the Offload app at any time.

7. Authority. If I am signing on behalf of another person, I confirm that I have legal authority to do so (for example as a parent of a minor, legal guardian, health care proxy or agent under a health care power of attorney, attorney-in-fact under a durable power of attorney, personal representative of an estate, or with the patient's express permission where the patient is able to give it), and I will provide documentation of that authority to Offload or a Discloser on request.

8. Copies. A photocopy, fax, or electronic copy of this authorization is as valid as the original.

9. Electronic signature. By typing my name and clicking “Sign” I agree to sign this document electronically under the U.S. ESIGN Act and the Uniform Electronic Transactions Act, and I agree that my electronic signature has the same legal effect as a handwritten signature. Offload records the signer's name, the date and time, the IP address, and the browser used to sign, and keeps that record with this document.

Letter of Authorization to Act on My Behalf

Account holder

Full name as entered in the app

Authorizing person

The signer, if signing for another person

Contact

The signer's email and phone, so a company can verify the letter

Authorized representative

Lazarus LLC d/b/a Offload, and its designated agents

Valid

12 months from signature unless revoked earlier in writing

To whom it may concern:

I authorize Lazarus LLC d/b/a Offload (“Offload”) and its designated agents to communicate with your organization on my behalf, or on behalf of the account holder named above where I have authority to act for them, regarding any account, membership, subscription, policy, or service held with you.

This authorization covers: discussing account status, charges, balances, plan details, and billing history; requesting itemized statements, contracts, and other documents; negotiating balances, payment plans, promotions, discounts, and fee waivers; disputing charges; cancelling services, subscriptions, or memberships; requesting refunds, credits, and prorated adjustments; and requesting written confirmation of any of the above.

This authorization does not cover, and Offload is not permitted to: open new accounts or lines of credit; change the ownership of the account; add or remove authorized users; change the mailing address, email, or phone number of record except to add Offload as a contact for this matter; make payments, transfers, or withdrawals from any account; or purchase products or services, other than accepting a promotional rate or plan change that lowers the cost of a service I already have.

Please treat requests from Offload agents who reference this letter as requests from me. You may verify this letter by contacting me at the email or phone number above. Please send written confirmations to me and to Offload.

I may revoke this authorization at any time by written notice to your organization and to Offload at support@offload.help.

Electronic signature. By typing my name and clicking “Sign” I agree to sign this letter electronically under the U.S. ESIGN Act and the Uniform Electronic Transactions Act. Offload records the signer's name, the date and time, the IP address, and the browser used to sign.