By signing below, I authorize Insyte Biomed, LLC to disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions, to any individual or organization duly assigned by Insyte Biomed, LLC for my care. My complete health record may be stored and disclosed in electronic copy or access via a web-based portal or by hard copy at my request, at the duration of the past, present, and future periods.
I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: Insyte Biomed, LLC, 989 W. Kennedy Blvd. Ste 203, Orlando, FL 32810.
I understand that:
In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
I understand that I do not need to give any further permission for all my protected patient health records and information.
I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.