Name: Radical Elevation

Address: 3551 E Bonanza Rd, Suite 101, Las Vegas, NV 89110

Phone: (702) 608-1488

Fax: (702) 441-1524

Email: info@radicalelevation.com

Terms of Consent & Confidentiality

I understand that:

• The purpose of this disclosure is to assist in the coordination of services for me by Radical Elevation. Unless otherwise specified, this information may be disclosed in writing, verbally, via fax, or through electronic communication.
• My records are protected under Federal rules governing the disclosure of confidential patient information (42 CFR Part 2 and HIPAA). Information about my participation in treatment cannot be disclosed or re-disclosed without my written consent unless otherwise permitted by applicable laws and regulations.
• I have the right to receive a copy of this authorization. Any cancellation or modification of this authorization must be in writing. I also have the right to revoke this authorization at any time unless Radical Elevation has already taken action in reliance upon it. Any revocation must be submitted in writing and received by Radical Elevation at 3551 E Bonanza Rd, Ste 101, Las Vegas, NV 89110 to be effective.
• Radical Elevation shall not condition treatment upon my signing of this authorization, and I have the right to refuse to sign this form without affecting my ability to receive care.
• Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected under the HIPAA Privacy Rule.

This authorization will remain in effect for one (1) year from the date signed unless I specify an earlier expiration date below: