Consent to Share Information with Qualiphy
By accepting this consent, you authorize Vynova Health LLC to share information with Qualiphy and related clinical partners for telemedicine intake, provider review, care coordination, and related operational support.
1. Information and Purpose
- Information that may be shared includes name, email, phone number, date of birth if collected through an approved secure process, state, preferred language, program interest, payment status, intake status, account status, and support information needed to coordinate services.
- Sharing supports intake routing, service availability checks, provider review, telemedicine coordination, documentation, prescription review if clinically appropriate, status updates, and legal or regulatory compliance.
2. No Guarantee and Separate Provider Terms
Sharing information with Qualiphy does not guarantee approval, diagnosis, prescription, medication availability, specific treatment, specific result, or shipping timeline. Qualiphy or the applicable provider may have separate privacy notices, terms, and consent documents.
3. Withdrawal
You may withdraw this consent by contacting compliance@joinvynova.com. Withdrawal may prevent Vynova from coordinating clinical intake or related services and does not affect disclosures already made before the withdrawal was processed.
Acknowledgment: You authorize Vynova Health to share information with Qualiphy and related clinical partners, understand the purpose of the sharing, understand provider approval and prescriptions are not guaranteed, and understand Qualiphy or the provider may have separate privacy and consent documents.
Name: ___________________________
Date: ___________________________
Electronic Signature / Checkbox: ___________________________
Consent Version: qualiphy_share_v2_2026_05