Healthlynked Authorization Release of Information
First Name:
Last Name:
I, authorize Dr. Auguste Fortin H Vi to release any and all healthcare information about me to my HealthLynked personal health record (PHR) for my own uses and purposes. I acknowledge that such healthcare information may include the following: x rays, clinical diagnosis, histories of present illnesses, immunizations, allergies, prescription drug information, laboratory results, diagnostic screening and testing, clinical procedures, medical research, clinical trials, billing, account, and insurance information.
I acknowledge that such healthcare information may include information regarding mental health screenings and/or treatment, including psychotherapy notes; HIV/AIDS, infectious disease, sexually transmitted infection testing, screening, diagnosis, and/or treatment; genetic testing; history of domestic violence, child abuse, and/or family abuse; and, substance/ alcohol use and treatment history.
I acknowledge that with this authorization Dr. Auguste Fortin H Vi may disclose any information or records (within the scope of the authorization) that Dr. Auguste Fortin H Vi has received about me from other healthcare practices, providers or facilities. Dr. Auguste Fortin H Vi may, within its discretion, withhold from disclosure any of the above information as permitted or required by law.
Access to treatment or services may not be denied to me if I decline to sign this Authorization or revoke my Authorization. However, without this Authorization, my Dr. Auguste Fortin H Vi will not electronically release my healthcare informat io n to my HealthLynked PHR. I may revoke this authorization at any time. Such revocation will take effect immediately to the extent that my doctor has already acted based on this Authorization.
I may revoke this Authorization by unlinking or removing access for Dr. Auguste Fortin H Vi as a health care provider with which I want to be connected on my HealthLynked account. However, I acknowledge that data previously submitted by Dr.Auguste Fortin H Vi as authorized by me prior to my subsequent revocation of this Authorization will remain in my HealthLynked account. I understand that I may delete my HealthLynked account any time.
This authorization shall end upon the earliest of: a) the termination of the connection between my healthcare Dr. Auguste Fortin H Vi and my HealthLynked Account.
For Authorized Representatives of Patients younger than 18 years old: This Authorization shall expire upon the earliest of: (1) the date the minor reaches the age of 18; or (2) the date HealthLynked receives written revocation from the minor, as an emancipated minor with legal authority to manage his/her own healthcare.
I understand that the information submitted to my HealthLynked account is subject to the privacy and security protections of applicable Federal and State laws. I further understand and acknowledge that the manner in which HealthLynked protects my personal information is detailed in the HealthLynked Privacy Policy and the HealthLynked Terms of Use.
I have the right to receive a copy of this Authorization and may do so by clicking [Print] below.
Signed on: 2024-05-03 18:54
Name:
Date Of Birth:
By clicking [ACCEPT], I acknowledge and agree to the terms of this Authorization.
