HIPAA Consent & Authorization
CONSENT AND AUTHORIZATION FOR RELEASE OF CONFIDENTIAL & PROTECTED HEALTH INFORMATION
I hereby authorize my health care provider (“Covered Entity”), to disclose to Medikarma, Inc. electronic health information including:
[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
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.
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.
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.
Last updated on 18 October, 2022.