Authorization for use or Disclosure of Health Information

Sayana Medical: Authorization for Use or Disclosure of Health Information

Completion of this document authorizes the disclosure and/or use of health information about you. Failure to provide all information may invalidate this Authorization.

Use and Disclosure of Health Information
Name of Patient(Required)
MM slash DD slash YYYY

I hereby authorize:

Sayana Medical & Wellness Center

14006 Riverside Drive, Unit 18 Sherman Oaks, CA - 91423

818-331-4386

866-539-9507

To release to:

Please select how you would like your medical records released and type the info in the bottom line(Required)

To release the following information:

Choose one(Required)
Purpose of requested use or disclosure(Required)

Expiration

This Authorization expires one (1) year from the date signed.

Patient Rights

I may refuse to sign this Authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits.

I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of.

I may revoke this authorization at any time, but I must do so in writing and submit it to my healthcare center.

My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this Authorization.

I have a right to receive a copy of this authorization.

I understand information disclosure pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality law (HIPAA). If the disclosure is to Sayana Medical & Wellness Center, the Center will only release as allowed by law.

Select one(Required)
MM slash DD slash YYYY

Medical Records Request will be submitted to Sayana Medical Spa and Wellness Center