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HIPAA AUTHORIZATION

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

Patient Name:

Date of Birth:

1. My Authorization

I authorize the following using or disclosing party:

To use or disclose the following health information

I understand if I choose 'Other History' this could take much longer to accumulate full history of all services received at Skinlogic Med Spa.

The above party may disclose this health information to the following recipient:

If you selected 'Other medical spa or physicians office' please provide us with their full information below:

The purpose of this authorization is (check all that apply):

Check all that apply

At my request

Other

If you selected 'Other' please explain:

My Rights

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it at my request. A copy of this authorization is as valid as the original.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

September 28, 2022 2:53 pm PDT

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 73.169.190.108