AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

(Tele-Mental Health | HIPAA | 42 CFR Part 2 | Utah Law | Employer-Sponsored Programs)

Last Updated: Feb 19, 2026

This Authorization is provided in connection with tele-mental health services delivered by Engine Tech LLC (DBA Skyler Health) (“Skyler Health”).

This Authorization complies with:

  • The Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164

  • 42 C.F.R. Part 2 (Confidentiality of Substance Use Disorder Records), if applicable

  • Utah Code Title 26B (Health), Title 58 (Occupations & Professions), and related confidentiality provisions

  • The Electronic Signatures in Global and National Commerce Act (E-SIGN)

  • Utah Uniform Electronic Transactions Act (UETA)

1. Purpose of This Authorization

I understand that Skyler Health provides tele-mental health services, including AI-supported engagement tools, licensed therapy services, and care coordination.

This Authorization permits Skyler Health to use, obtain, and/or disclose certain health information for the purpose of:

  • Tele-mental health treatment

  • Care coordination with my treating providers

  • Referral management

  • Continuity of care

  • Employer-sponsored program administration (as described below)

Skyler Health will disclose only the minimum necessary information consistent with applicable law.

2. Information Covered by This Authorization

This Authorization applies to:

  • Mental health records

  • Telehealth session documentation

  • Treatment summaries

  • Medication information

  • Care coordination communications

  • Behavioral health screening results

  • AI-supported interaction summaries (where clinically relevant)

If applicable, this may include:

  • Substance Use Disorder (SUD) treatment records

  • Diagnosis and treatment information

  • Medication-assisted treatment information

3. 42 CFR Part 2 – Substance Use Disorder Records

If I have received substance use disorder services from Skyler Health, I understand:

  • My SUD records are protected under federal law (42 C.F.R. Part 2).

  • These records may not be disclosed without my specific authorization unless otherwise permitted by law.

  • Any recipient of SUD records is prohibited from redisclosing such records unless expressly permitted by 42 C.F.R. Part 2.

NOTICE TO RECIPIENT OF SUD INFORMATION:

This information has been disclosed from records protected by federal confidentiality rules (42 C.F.R. Part 2). Federal law prohibits further disclosure unless expressly permitted by the written consent of the individual or as otherwise permitted by law.

4. Employer-Sponsored Mental Health Programs

If my access to Skyler Health services is provided through my employer:

  • My employer will NOT receive my clinical records, session notes, diagnoses, or detailed treatment information.

  • Skyler Health may provide my employer with de-identified or aggregated utilization data for program administration and reporting purposes.

  • Identifiable health information will not be shared with my employer without a separate, specific authorization.

This protects the confidentiality of my clinical information.

5. Tele-Mental Health Specific Acknowledgments

I understand that:

  • Services are delivered via secure electronic communications.

  • Telehealth carries inherent technology risks (e.g., internet disruption).

  • Sessions may be documented electronically.

  • AI-supported tools are assistive and not substitutes for licensed clinical judgment.

  • Skyler Health does not provide emergency services.

If I experience a crisis, I should contact 988, 911, or local emergency services.

6. Voluntary Authorization

I understand:

  • I am not required to authorize disclosures beyond what is legally necessary for treatment.

  • Refusal to authorize certain disclosures may limit care coordination I request.

  • This Authorization is voluntary.

7. Revocation

I may revoke this Authorization at any time by emailing:

care@skylerhealth.com

Revocation will be effective upon receipt and processing.

Revocation does not apply to:

  • Disclosures already made in reliance on this Authorization

  • De-identified or aggregated data already created

  • Uses required or permitted by law

8. Expiration

This Authorization expires on the earliest of:

  • 180 days from digital acknowledgment

  • Termination of services

  • Revocation by me

Unless otherwise required by law.

9. Redisclosure

I understand that:

  • Information disclosed under this Authorization may be subject to redisclosure by recipients not covered by HIPAA.

  • Healthcare providers remain bound by applicable confidentiality laws.

  • SUD records remain protected under 42 C.F.R. Part 2.

10. Digital Acknowledgment & Electronic Signature

By selecting “I Agree” or otherwise digitally acknowledging this Authorization within Skyler Health’s secure platform, I confirm:

  • I have read and understand this Authorization.

  • I authorize the use and disclosure of my health information as described.

  • My electronic acknowledgment constitutes a legally binding signature under federal and Utah law.

  • No wet signature is required.