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Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
1. I authorize Wellness By Science USA, LLC. (WBS) to use and disclose the protected health information described below to whom they deem fit.
2. This medical information may be used as authorized to receive this information for medical treatment or consultation, billing or claims payment, or other purposes deemed in my best interest by WBS.
3. This authorization shall be in full force and effect unless and until I revoke the same in writing at which time this authorization expires.
4. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
5. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
6. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature of patient or personal representative
Printed name of patient or personal representative and his or her relationship to patient