Hippa — Apothea

HIPPA Disclosure Agreement Form

Please fill out the form below prior to your appointment.

A copy will be provided upon completion.

Name

First Name

Last Name

Email

Information Authorization

I hereby authorize Apothea to use or disclose my protected health information related to my telehealth consultation.

Authorize

Electronic Signature of Individual or Representative

I understand that I may inspect or copy the protected health information described by this authorization I Inderstand that, at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whoes release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my health care will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to redisclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

First Name

Last Name

Authority or Relationship to Individual, if Representative

Date

MM

DD

YYYY

Expiration Date

This authorization will expire on date entered below. If no date or event is stated, the expiration date will be six years from the date of this authorization.

MM

DD

YYYY