I, the undersigned, hereby authorize a representative of Mindfully to use and/or disclose information from medical or financial record as specified above.
I understand and acknowledge that this authorization extends to all or any part of the records designated above, which may include documentation of treatment for mental health disorders, alcohol/drug abuse or dependence, and/or HIV/AIDs test results or diagnosis. I explicitly consent to the release of information as designated about. Furthermore, I consent to the release of the facsimile transmission of my protected health information as necessary.
This authorization may be revoked at any time to the extent that use and/or disclosure has not already occurred prior to your request for revocation. In order to revoke the authorization the individual/parent/legal guardian must submit a revocation request in writing to the disclosure. I also understand that Mindfully may charge a reasonable fee for the preparation, copying and postage as allowed by state law for copies of medical records.
I understand that Mindfully will not condition treatment, payment, enrollment or eligibility for benefits on the execution of this authorization. If the person/entity that received the above PHI is not a health care provider/health plan covered by federal privacy regulations, the PHI described above may be re-disclosed by such person/entity and will likely no longer be protected by the federal privacy regulations.
I understand that if I am requesting my physical records to be released to myself or another person/organization, I will need to complete an additional form titled Records Release Form.