HIPAA & Authorization
During the course of patient care, I may request and authorize the disclosure of my individually identifiable health information in writing as described below.
(a) To a Named entity
(b) Persons/organizations authorized to make requested disclosure of the information
(c) Providers/organizations to whom the disclosure may be made
(d) Specific description of information to be disclosed (including descriptive date(s))
(e) Specific purpose of the disclosure
(f) This authorization will expire (indicate date, or an event relating to you personally or to the purpose of the authorization)
Protected Health Information (“PHI”) may include information/documents regarding medical treatment of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointments and test results; account and billing information including, but not limited to, account balances, payments and payment arrangements, insurance claims status, and third-party financing.
I understand that the Health Insurance Portability and Accountability Act of 1996, and its implementing regulations (“HIPAA”) govern the terms of this Authorization.
I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to the persons/organizations identified in item (b) below providing the information. This right is described in Company’s Notice of Privacy Practices.
I understand that I am not required to sign this Authorization and my execution of this Authorization is not condition for treatment.
I understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipient listed above and, in that case, will no longer be protected by HIPAA. However, sale of PHI or use of the information for marketing by a third party that renumerates the provider should be explicitly stated.
HIPAA regulations authorize the release of PHI to other providers for the purpose of treatment, obtaining payment from third party payers, and the day-to-day healthcare operations of Prestige Medical Concierge. Other than those releases authorized by HIPAA, PHI will only be released to persons/organizations listed on this authorization and stated purpose.
This authorization shall be effective for twelve (12) months from the date of authorized signature
