AUTHORIZATION FOR RELEASE OR USE OF PROTECTED HEALTH INFORMATION
(HIPPA Compliant, 45 C.F.R. 164.508)
Authorization for Use and /or Disclosure:
By checking the box linked to this page, I Authorize the following persons, classes of persons, facilities and/or institutions to receive, use and disclose my Protected Health Information (hereinafter “PHI”) described below for the purpose identified herein:
1. eaglervc.org and its officers, directors, and employees;
2. Any third-party telemedicine firms and service providers engaged by eaglervc.org, to perform services on my behalf and the employees and independent contractors and service providers, including but not limited to nurses and doctors acting for or on behalf of such firms, telemedicine services, and service providers;
Information to be Used and/or Disclosed:
I authorize the use and disclosure of any and all Protected Health Information I provide directly to eaglervc.org, or which eaglervc.org may obtain under a separate authorization for release of PHI that I may sign in the future, to allow eaglervc.org to obtain Protected Health Information about me from any source other than me. Such PHI includes any and all medical records, including every page thereof, including but not limited to office notes, face sheets, history and physical, consultation notes, inpatient records, outpatient records, emergency room records, all clinical charts, order sheets, progress notes, nurses notes, doctors orders, treatment plans, admission records, discharge summaries, requests for and reports of consultations, correspondence, test results, statements, questionnaires and histories, photographs, imagining including CT scans, MRIs, X-rays, sonograms, videotapes, telephone messages, billing records, pharmacy/prescription records, etc.
Consent to Release and Use of Specially Protected PHI:
I understand that my express consent is required to authorize the use or disclosure of certain records, including information related to testing, diagnosis and/or treatment for HIV (the AIDS virus), sexually transmitted diseases, psychiatric, psychological or mental health disorders or treatment, or drug and/or alcohol use and treatment. I understand that the information to be used or disclosed pursuant to this Authorization may include such information. By my separate signature affixed here, I confirm that this Authorization is effective as to such records and Protected Health Information and I authorize the use and disclosure of this type of information.
Purpose of Authorized Use and Disclosure:
I have engaged eaglervc.org under a separate Service Agreement to consider, evaluate and seek amendment of my current disability rating. The use and disclosure authorized herein is for the purpose of permitting eaglervc.org, its employees, independent contractors and necessary third-parties access to all Protected Health Information necessary and or helpful to accomplish the task for which I have engaged eaglervc.org.
Term of Authorization and Right to Revoke:
Until the is a final determination of my Disability Rating and benefits by the VA.
I understand, in addition, that I have the right to revoke this Authorization at any time by a notice delivered to eaglervc.org in writing, except to the extent that PHI has already been released in reliance upon this authorization.
Acknowledgment of Possibility of Re-disclosure:
I understand that once the information released pursuant to this Authorization is received by the recipient, whether eaglervc.org or a third party, it may be re-disclosed and no longer protected under Privacy Laws. I agree to hold eaglervc.org, its Directors, Officers and employees harmless from any claim for damages that may occur thereby.
Copies As Effective as Original:
Any facsimile, copy or photocopy of this Authorization shall be as effective and enforceable as the original.
Authorization Not A Requirement of Services:
I sign this Authorization voluntarily and I understand that signing this Authorization is not required, but I have been advised that my failure to sign this Authorization may detrimentally impact the ability of eaglervc.org to obtain an increase in my VA Disability Rating or related benefits.