Michelle Dompenciel, M.D.

Healthlynked Authorization Release of Information

First Name:

Last Name:

I, authorize Dr. Michelle Dompenciel 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. Michelle Dompenciel may disclose any information or records (within the scope of the authorization) that Dr. Michelle Dompenciel has received about me from other healthcare practices, providers or facilities. Dr. Michelle Dompenciel 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. Michelle Dompenciel 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. Michelle Dompenciel 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.Michelle Dompenciel 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. Michelle Dompenciel 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: 2022-01-27 03:10

Name:

Date Of Birth:

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