Provider Authorization


By accepting where indicated below, I hereby authorize [insert Name, relationship, and email address] (hereinafter, “Provider”) to have access to my ikioo personal health record.  By authorizing Provider to have access to my ikioo account, I acknowledge and agree that I am authorizing Provider to:


  • Review the following elements of my personal health record as maintained by ikioo (check each that applies):
    • Notes
    • Labs
    • Diagnositics
    • Medications
    • Providers
    • Vision Profile
    • Dental History
    • Pharmacy
    • Insurance
    • Insurance Coverage
    • Medical Facility
    • Records
    • Advanced Directives
    • Code Status
    • Past Surgical History
    • Past Medical Hisotry
    • Family Hisotry
    • Travel History
    • Social History
    • Genetics Profile
    • Allergy History
    • Immunization History
    • Menstrual History
    • Next of Kin
  • Record recommendations or other information on and/or communicate with me through my personal health record; and
  • [Other? Please describe].

I understand that that once my information is disclosed to Provider, I will no longer have control over my health information and Provider may re-disclose my health information in such manner as Provider may determine from time to time.  ikioo will not be responsible for re-disclosures by Provider. 


I also understand that the Provider may submit recommendations and comments onto my ikioo personal health record or directly to me.  I understand that these recommendations are the Provider’s alone and ikioo is not responsible for the accuracy and/or representations made by the Provider. 


This authorization shall expire upon (1) my termination of my ikioo account; or (2) my removal of Provider as an authorized user of ikioo.  I may terminate my ikioo Account or terminate a Provider by following the directions on my ikioo account at any time.  In addition, I can request assistance from ikioo in so doing by sending an email to [add address].


By signing where indicated below, I acknowledge that: 


I may revoke this Authorization at any time.  Such revocation will promptly take effect except to the extent that my Provider has already acted based on this Authorization.  I may revoke this Authorization by removing Provider as an authorized user of my ikioo account. 


Signed on [Insert Date Automatically]


Fill in the following information:


Last Name, First Name and MI:  ______________________


Date of Birth:  [DD/MM/YYYY] ____________________


Relationship to subject of information: [Place “x” in the appropriate box below]


[  ]  Self


[  ]  Parent/Guardian/Other Legal Representative


By clicking [I ACCEPT], I acknowledge and agree to the terms of this authorization.