HIPAA Authorization Form

Patient Information

Full Name

First

Last

Date of Birth

Email Address

Phone Number

Person or Entity

Full Name of Person or Entity

Phone Number

Fax

Relationship to the Patient

Email Address

the any Health

Consent Purpose

BodyByBariatrics is authorized to disclose my Protected Health Information (PHI) to the Person or Entity listed on this form

I consent

I understand that the information used or disclosed may be subject to re-disclosure by the Person or Entity receiving it, and would then no longer be protected by federal privacy regulations.

I consent

I may revoke this authorization by notifying BodyByBariatrics in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

I consent

Signature

Clear Signature

Date

Printed Name of Patient or Parent/Guardian

First

Last

Relationship to Patient