HIPAA Consent & Authorization

CONSENT AND AUTHORIZATION FOR RELEASE OF CONFIDENTIAL & PROTECTED HEALTH INFORMATION

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I hereby authorize my health care provider (“Covered Entity”), to disclose to Medikarma, Inc. electronic health information including:

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[x] Diagnosis 

[x] Laboratory Test Results 

[x] All other healthcare information related to the releasing party 

The purpose of the use or disclosure authorized herein is: 

[x] Continuation of care and coordination of services

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I understand that my records are protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may re-disclose the deidentified information and it may no longer be protected by the HIPAA privacy law. 

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I also understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. This authorization may be revoked by contacting the Covered Entity. 

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I understand that the Covered Entity seeking this authorization is not conditioning treatment, payment, enrollment or eligibility for benefits on whether I sign the authorization. 

I understand that I am entitled to receive a copy of this authorization after it is signed. 

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Last updated on 18 October, 2022.