Regarding usage of all forms of communication (mail, email, phone, fax, text messaging): there are risks that confidential information may accidentally be transmitted to people not authorized to receive such information. Although STARS Plastic Surgery, "practice", institutes mechanisms available to avoid such risks, I am aware of the potential for breach. I hereby authorize the practice to release my medical information via the forms of communication detailed above to any referring physician, hospital, treatment facilities and other persons for the purposes of diagnosis and treatment. I further authorize the practice to release my name and address to other parties for the sole purpose of receiving medically related information via the above means of communication. In accordance with the federal government privacy rules implemented through the HEALTHCARE PORTABILITY ACT OF 1996 (HIPAA), in order for your physician or staff to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a medical emergency, the law stipulates that these rules maybe waived. I authorize the practice to release my medical information concerning my medical care, verbally or in writing as set forth above with the exception to the following individuals detailed below.