Charles S Li, M.D.

Healthlynked Authorization Release of Information

First Name:

Last Name:

I, authorize Dr. Charles S Li 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. Charles S Li may disclose any information or records (within the scope of the authorization) that Dr. Charles S Li has received about me from other healthcare practices, providers or facilities. Dr. Charles S Li 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. Charles S Li 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. Charles S Li 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.Charles S Li 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. Charles S Li 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: 2022-06-30 08:09

Name:

Date Of Birth:

By clicking [ACCEPT], I acknowledge and agree to the terms of this Authorization.