Form – Medical Release InstagramThis field is for validation purposes and should be left unchanged. HIPAA Privacy Authorization Form **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**Name of the Signatory(Required)I, hereby acknowledge that I have read and understand the policies of Blue Sky Health and Wellness. Phone(Required)Email(Required) I authorize Dr Jennifer Sims, D.C. to speak and disclose the protected health information described below to:*(Required)Enter the individual seeking the information here:Effective Period: This authorization for release of information covers the period of heathcare from:*(Required)Please enter effective dates from/to or enter ALL for past, present and future periods.A. Extent of Authorization: I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).*(Required)Please type YES to authorizeB. Extent of Authorization: I authorize the release of my complete health record with the exception of the following information:*(Required) Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Other (please specify in comment box below) Comment BoxNotes to the DoctorAcknowledgements: This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. This authorization shall be in force and effect until the effective dates listed in this form at which time this authorization expires. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.*(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.Please type full name of patient and/or guardian.(Required)Today's Date(Required) MM slash DD slash YYYY Please do not submit any Protected Health Information (PHI).CAPTCHA Please do not submit any Protected Health Information (PHI).
