Authorization for the Use & Disclosure of Health Information
This consent document authorizes the use and disclosure of health information about you. During your intake for B Brand, the following information and more will be requested from you: Patient Name, Date of Birth Address, Phone Number, Health History and Personal Lifestyle Information.
Failure to provide all information requested may invalidate this Authorization.
By clicking ‘‘I acknowledge and agree to the Authorization for the Use and/or Disclosure of Health Information Policy’ you acknowledge the below and release all health information pertaining to your medical history, mental or physical condition, and treatment received, including demographic information.
This Authorization is valid until you are no longer a subscriber to B Brand or within five (5) years from the termination date or applicable state law, whichever is earlier.
I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to support@bholdinggroup.com.
I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by Federal or State law. However, State law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law. M&D Integrations, Inc. will not condition my treatment on whether I provide authorization for the requested use or disclosure.
I understand that I have the right to: inspect or copy the protected medical information to be used or disclosed as permitted under Federal or State law; refuse to sign this Authorization; and receive a copy of this Authorization. If I am requesting information for myself or for a third party, a reasonable and appropriate fee may be assessed for copying the information. I have read the above information and authorize the disclosure of my information for the purpose described herein.
By clicking ‘‘I acknowledge and agree to the Authorization for the Use and/or Disclosure of Health Information Policy’ you acknowledge that you have read and agree to the terms of this Authorization.