Medical Records Authorization
Permission for the professionals and organizations involved in a service you request to send the information Vitals Vault needs to coordinate that service.
Effective September 2, 2026
This authorization lets the independent health professionals, medical groups, laboratories, specimen-collection providers, and pharmacies involved in services you request through Vitals Vault send relevant medical information to Vitals Vault Inc.
If I sign for a minor or another person for whom I have legal authority, “I,” “me,” and “my” refer to that person where appropriate. I confirm that I have authority to sign this authorization for that person.
Information covered
I authorize disclosure of information reasonably related to services I request through Vitals Vault, including my identity and contact details, health history, medications, allergies, symptoms, intake responses, lab orders and results, consultation records, provider instructions and messages, prescriptions, pharmacy and fulfillment information, and related billing or service records.
Who may disclose it
Any licensed professional, medical group, laboratory, specimen-collection provider, pharmacy, or other health care organization involved in a product or service that I request through Vitals Vault.
Who may receive it
Vitals Vault Inc. and vendors acting under contract for Vitals Vault to host, secure, transmit, organize, display, support, or otherwise provide the requested service.
Purpose
To evaluate and fulfill services I request, coordinate orders and care, receive and show results and records in my account, provide account and customer support, support continuity of care, and meet legal and compliance obligations.
Expiration
This authorization expires one year after I close my Vitals Vault account, or earlier if applicable law requires. Closing my account does not shorten a medical provider's legal record-retention duties.
Revocation
I may revoke this authorization by emailing support@vitalsvault.com or writing to Vitals Vault Inc., 1700 7th Ave, Suite 2100, Seattle, WA 98101. Revocation applies only after it is received and processed. It does not affect a disclosure already made in reliance on this authorization. Vitals Vault may be unable to coordinate an optional service after revocation.
Important notices
I understand that signing is voluntary. A health care provider generally may not condition treatment, payment, enrollment, or benefit eligibility on this authorization, except where permitted by law. Information disclosed to Vitals Vault may no longer be protected by HIPAA, but it remains subject to Vitals Vault's privacy commitments and other applicable laws. I may view and save a copy of this authorization.
By accepting the Vitals Vault consent bundle, I confirm that I have read this authorization and sign it electronically.