Authorization To Communicate Freely with Representative

Patient Name*

First NameLast Name

Patient Email*

example@example.com

Patient Date of Birth*

Date

Authorization to discuss personal/medical information with Representative:

Representative Name and Relationship to Patient*

This message and any attached files may contain confidential Personal Health Information and other HIPAA protected information. The information is intended only for the use of the individuals or entities originally named as addressees. The improper disclosure of such information may be subject to civil or criminal penalties. If this message has reached you in error, please contact the sender and destroy this information.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Specialty Natural Medicine. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer
with the right to contest a claim under my policy.

I understand that my authorization includes Behavioral Health, substance abuse, sexually transmitted disease or HIV information, it may include; (i) information concerning whether an individual has been the subject of an human immunodeficiency virus (HIV) - related test, has HIV, an HIV related illness, acquired immunodeficiency syndrome (AIDS), and/or including information pertaining to the individual's contact. I am hereby specifically authorizing the release of all information or medical records relating to these diagnosis, testing or treatment unless specifically excluded above.

I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand that records released via email may be viewable by 3rd parties during transit and may be viewable by manager or administrators of email networks.

I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.

I have read all the terms and conditions and understand the risks of authorizing my representative full authorization to discuss and receive my protected personal health information.*

I agree.

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Specialty Natural Medicine, Inc PC.*

I accept

Patient or Patient’s Parent/Guardian Signature:*

Date*

Date