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.
Date of Birth:
1. My Authorization
I authorize the following using or disclosing party: Company authorizing to disclose info.Skinlogic Med Spa
To use or disclose the following health information Please SelectInjectable HistoryOther History
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: Please SelectMyselfOther medical spa or physicians office
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
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.
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Your legal name
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If you have questions about the contents of this document, you can email the document owner.
Document Name: HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
Agree & Sign