1. Purpose
This Authorization allows you to give another person access to some or all of your MedLocker information. A caregiver may be a family member, friend, legal guardian, personal representative, care coordinator, advocate, or other person you trust. Caregiver sharing is user directed. You should authorize only people you trust, because a caregiver may view, download, copy, screenshot, use, or further disclose information outside MedLocker.
2. MedLocker User
Full Legal Name
Date of Birth
Phone
3. Authorized Caregiver or Representative
Caregiver Name
Relationship
Phone
Organization, if any
4. Access Level
Select
Access Level
Description
View Only
May view selected information but may not download, export, upload, edit, or share except as technically unavoidable through viewing.
View and Download
May view and download selected information, records, summaries, reports, or exports.
Upload and Add Information
May upload documents, add notes, enter information, or help organize records.
Request Records
May help initiate records requests or connect data sources, subject to additional authorization if required.
Manage Sharing
May help share information with providers or other recipients I approve or within the selected scope.
Manage Consents
May help manage platform consents, caregiver access, and optional program consents only if specifically permitted.
Emergency Information Only
May view only emergency profile information selected by me.
Custom Access
Describe: ____________________________________________
5. Information Included
- All information in my MedLocker account.
- Clinical records only.
- Medications, allergies, conditions, immunizations, and emergency profile only.
- Lab and imaging results.
- Claims, insurance, cost, and billing records.
- Uploaded documents.
- AI assisted summaries and timelines.
- Sensitive categories only if selected below.
- Custom scope: ____________________________________________
6. Sensitive Categories
I authorize caregiver access to the following sensitive categories only if selected. If not selected, MedLocker will restrict access where technically and operationally feasible, but I understand some records may contain mixed information.
- Mental health records.
- Substance use disorder treatment records.
- HIV/AIDS, communicable disease, or infectious disease records.
- Genetic testing information.
- Reproductive health, fertility, pregnancy, abortion, contraception, or family planning records.
- Sexually transmitted infection records.
- Minor dependent records, subject to applicable law.
- Other: ____________________________________________
7. Duration and Revocation
This Authorization remains in effect until I revoke it, the expiration date or event I specify here: ____________________________________________, my account is closed, or Alpine Labs determines continued access may violate law, create security risk, or conflict with rights.
I may revoke this Authorization at any time through MedLocker controls or by contacting privacy@alpinelabs.ai. Revocation stops future caregiver access after Alpine Labs processes the request, but may not delete information already viewed, downloaded, copied, screenshot, or disclosed outside MedLocker.
8. Caregiver Responsibilities
Use access only to help the MedLocker user or dependent identified above.
Protect account credentials and not share access with unauthorized people.
Respect the privacy and preferences of the MedLocker user.
Not use information for unlawful, harmful, discriminatory, fraudulent, or unauthorized purposes.
Understand that information obtained from MedLocker may be sensitive and may not be governed by HIPAA once shared directly outside a HIPAA regulated relationship.
9. Minor or Dependent Records and No Medical Advice
If this Authorization relates to a minor child or dependent, the signer represents that they have legal authority to grant access. Minor records may be subject to additional state laws, adolescent confidentiality protections, or provider restrictions. MedLocker may limit access if required by law or product capability. Caregiver access does not make Alpine Labs a healthcare provider and does not create a medical advice, diagnosis, treatment, emergency, fiduciary, or care management relationship.
10. User Acknowledgment
By signing or accepting electronically, I authorize Alpine Labs to provide the caregiver identified above with the selected access to my MedLocker information, subject to MedLocker product capabilities, my settings, the Privacy Policy, Terms of Service, and applicable law.
Signature
Signature
Printed Name
Date
Representative Name, if applicable
Relationship or Authority
Caregiver Acknowledgment, if used