HIPAA Privacy Authorization Form

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

Date

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