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HIPAA Consent & Authorization

Consent and Authorization for Release of Protected Health Information

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I hereby allow my healthcare provider to give Medikarma, Inc. my electronic health information, including:

  • [x] Diagnosis

  • [x] Laboratory Test Results

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

 

Reason for Disclosure

  • [x] Continuation of care and coordination of services.

 

Your Privacy Rights and Legal Terms

  • Federal privacy rules under HIPAA protect my health records.

  • My health information listed above will be shared because of this form.

  • The company receiving this information may share it again once my identity is removed. After that, federal HIPAA privacy laws may no longer protect the information.

  • I can cancel this permission at any time by contacting my healthcare provider. However, I cannot cancel it for information that has already been shared while the permission was active.

  • My healthcare provider cannot refuse to treat me if I do not sign this form. They also cannot deny payment or health benefits based on my choice.

  • I have the right to get a copy of this form after I sign it.

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