Patient Disclosure
I understand that the report generated from my images is intended for use by trained health care providers to assist in evaluation, diagnosis and treatment. I further understand that the report is not intended to be used by individuals for self-evaluation or self-diagnosis.
I understand that the report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings of the areas discussed in the report.
As required by the Privacy Regulations, Family Health Thermal Imaging & Detox may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.
I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office: EMI, Electronic Medical Interpretations
Patient health information authorized to be disclosed: thermal images and related health history
For the specific purpose of: interpretation of said images
Effective dates for this authorization: appointment date through 7 years
This authorization will expire at the end of the above period.
I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.
I understand I have the right to:
1. Revoke this authorization by sending written notice to this office and that revocation will not affect this office's previous reliance on the uses or disclosure pursuant to this authorization.
2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization.
3. Inspect a copy of patient health information being used or disclosed under federal law.
4. Refuse to sign this authorization.
5. Receive a copy of this authorization.
6. Restrict what is disclosed with this authorization.
I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.