GenoPalate, Inc. and its affiliates are referred to in this document as GenoPalate, we, us, or our. You are referred to as you or the patient.
By checking the applicable box or otherwise electronically indicating your agreement within your GenoPalate account, you acknowledge that you have read, understood, and agree to this Practitioner Portal Patient Authorization.
1. Purpose of this authorization
This authorization allows GenoPalate to disclose your genetic nutrition information to one or more clinics, spas, or other wellness or healthcare providers that you choose to connect to your GenoPalate account through the Practitioner Portal.
The purpose of this disclosure is to allow your chosen provider or providers to review and use your GenoPalate information to help support your care, wellness services, or treatment plans.
2. Information that may be disclosed
You authorize GenoPalate to disclose the following categories of information about you through the Practitioner Portal, to the extent they are available in your account
-
Genetic nutrition analysis and related reports
-
Nutrient and food recommendations and scores
-
Information about how your genes may influence traits related to nutrition, such as food tolerances, nutrient needs, or eating behaviors
-
Questionnaires, program selections, and other information you have provided to GenoPalate in connection with our genetic nutrition services
-
Coaching notes, program recommendations, and other information created by GenoPalate about you in connection with our services
-
Basic identifying information and account identifiers that GenoPalate reasonably needs to confirm your identity and match you to your Provider, such as your name, date of birth, contact information, and internal account ID
GenoPalate will not share your payment card numbers, account passwords, or direct access credentials to your GenoPalate account with your Provider.
3. Who may receive and use your information
By agreeing to this authorization, you instruct and authorize GenoPalate to disclose your information, as described above, to
-
Any clinic, spa, healthcare provider, or wellness provider that you choose to connect to your GenoPalate account using the Practitioner Portal
-
The authorized staff, contractors, and personnel of that Provider who are involved in your care, wellness services, or related administrative activities
You understand that GenoPalate does not select your Provider, does not control your Provider’s internal systems or records, and is not responsible for your Provider’s use or disclosure of your information once it has been shared.
Your Provider’s use and disclosure of your information will be governed by its own privacy practices and any applicable laws or regulations, which may differ from the protections provided by GenoPalate’s Privacy Policy.
4. Sensitive nature of genetic information
You understand that genetic information is considered sensitive personal information. Your genetic nutrition information may reveal how your body may respond to certain nutrients, foods, or wellness factors.
Once your information is disclosed to your Provider, it may become part of your medical record or client file with that Provider and may be used and disclosed by that Provider according to its own policies and applicable law.
5. Voluntary nature of this authorization
You understand that
-
Agreeing to this authorization is voluntary
-
You may choose not to authorize GenoPalate to share your information with a Provider
-
If you do not agree, the Provider you wish to work with may not be able to view or use your GenoPalate information as part of your care
Except where permitted by law, your Provider should not condition your treatment or eligibility for services on whether you sign this authorization. However, certain services that specifically rely on access to your GenoPalate information may not be available if you do not provide this authorization.
6. Duration of this authorization
Unless you revoke this authorization earlier as described below, this authorization will remain in effect for as long as
-
Your GenoPalate account remains active and
-
A Provider remains connected to your account through the Practitioner Portal
You may disconnect a Provider from your account at any time within your GenoPalate account settings. When you disconnect a Provider, GenoPalate will stop providing that Provider with ongoing access to your information through the Practitioner Portal.
Information that was previously disclosed to your Provider may continue to be maintained and used by your Provider in accordance with its own policies and applicable law.
7. Right to revoke this authorization
You may revoke this authorization, in whole or in part, at any time by
-
Changing your settings in your GenoPalate account to disconnect a Provider from the Practitioner Portal, and/or
-
Sending a written request to GenoPalate at privacy@genopalate.com or to the postal address listed in our Privacy Policy
Your revocation will not affect any disclosures that GenoPalate made in reliance on this authorization before the revocation was received and processed. Your revocation also will not require your Provider to remove or delete information it has already received, subject to any rights you may have directly with that Provider.
8. Potential for redisclosure
Once your genetic nutrition information is disclosed to a Provider, GenoPalate cannot guarantee that it will remain subject to the same privacy protections that apply when it is held only by GenoPalate.
Your Provider may be permitted or required by law to use or disclose your information in ways that are not governed by GenoPalate’s Privacy Policy. In some cases, your information may be redisclosed by your Provider and may no longer be protected by certain privacy laws.
9. Relationship between GenoPalate and your Provider
You understand and agree that
-
GenoPalate is not a medical practice and does not provide medical diagnosis, treatment, or medical advice
-
Your Provider is responsible for your medical care or wellness services, not GenoPalate
-
GenoPalate provides genetic nutrition analysis and related services that your Provider may choose to use as one input into your care
-
Any questions about how your Provider uses or protects your information should be directed to your Provider
Nothing in this authorization creates a medical or provider–patient relationship between you and GenoPalate.
10. Electronic agreement and records
By checking the applicable box or otherwise electronically indicating your agreement within your GenoPalate account, you
-
Confirm that you are the individual associated with the GenoPalate account or that you are legally authorized to act on that individual’s behalf
-
Agree to the terms of this Practitioner Portal Patient Authorization
-
Instruct and authorize GenoPalate to disclose your information to your connected Provider or Providers as described in this document
Your electronic agreement has the same legal effect as a handwritten signature to the fullest extent permitted by applicable law.
11. Contact information
If you have questions about this authorization or wish to revoke it, update your account settings or contact GenoPalate at
Email privacy@genopalate.com
Mail GenoPalate, Inc., Attn Privacy
10437 W Innovation Dr Suite 465
Milwaukee, WI 53226
