Authorization to Use or Disclose Protected Health Information

THERMOGRAPHIC HEALTH ADVANTAGE

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Check One

Agree to the below HIPPA terms

Decline HIPPA

ELECTRONIC SIGNATURE

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As the Privacy Regulations require, Thermographic Health Advantage, LLC may not use or disclose your protected health information without your authorization, except as detailed in our Notice of Privacy Practices.

Patient Health Information Authorization

I authorize Thermographic Health Advantage, LLC and its employees to use or disclose my Patient Health Information to the following individuals, entities, or business associates: EMI - Electronic Medical Interpretations.

I authorize the disclosure of my Patient Health Information, including thermal images and related health history, as well as all reports and results from previous tests such as MRI, CT scans, PET scans, mammograms, ultrasounds, and bloodwork. This information is provided to interpret the aforementioned images.

I acknowledge that I have the right to:

1. Revoke this authorization by sending a written notice to this office. I understand that revocation will not affect any actions taken by this office prior to receiving my notice.

2. Inspect a copy of the Patient Health Information being used or disclosed under federal law.

3. Refuse to sign this authorization.

4. Receive a copy of this authorization.

5. Restrict the information disclosed under this authorization.

I also understand that my decision to sign or not sign this document will not affect my treatment, payment, enrollment in a health plan, or eligibility for benefits, regardless of whether I authorize the use or disclosure of my protected health information.