Spa Me Now - HIPAA AUTHORIZATION

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
Date

MonthDayYear
Date
I. THE PATIENT. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
II. AUTHORIZATION. I authorize Spa Me Now ("Authorized Party") to use or disclose the following:
SELECT 1 OF THE 3 OPTIONS BELOW:

All of my medical-related information
My medical information ONLY related to the following issue:
Medical issue
Medical information only between the below dates:
START DATE

MonthDayYear
Date
END DATE

MonthDayYear
Date
SELECT 1 OF THE 3 OPTIONS BELOW, AND PROVIDE INFORMATION.

All of my medical-related information
My medical information ONLY related to:
My medical information ONLY from: to:
III. DISCLOSURE. The Authorized Party has my authorization to disclose Medical Records to:
SELECT 1 OF THE 2 OPTIONS BELOW.*

Any party that is approved by the Authorized PartyONLY the following party (fill in contact information below):
SELECT 1 OF THE 2 OPTIONS BELOW

Any party that is approved by the Authorized Party
ONLY the following party (fill in contact information below):
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
IV. PURPOSE. The reason for this authorization is:
Type a question*

GENERAL PURPOSE. At my request (general).TO RECEIVE PAYMENT. To allow the Authorized Party to communicate with me for marketing purposes when they receive payment from a third party.TO SELL MEDICAL RECORDS. To allow the Authorized Party to sell my Medical Records. I understand that the Authorized Party will receive compensation for the disclosure of my Medical Records and will stop any future sales if I revoke this authorization.OTHER.
If "OTHER", provide description:
Patient Name*

First NameLast Name
Signature*

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HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

I. THE PATIENT. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

II. AUTHORIZATION. I authorize Spa Me Now ("Authorized Party") to use or disclose the following:

III. DISCLOSURE. The Authorized Party has my authorization to disclose Medical Records to:

IV. PURPOSE. The reason for this authorization is: