Hipaa Authorization To Disclose Health Information
Recipients of My Information:
By signing below, I authorize the licensed mental health professional and their employees and agents (collectively referred to as "Licensed Mental Health Professional") to disclose health information about me, as detailed below, to FurryESA. Additionally, I authorize FurryESA to share the health information I provide with the Licensed Mental Health Professional who facilitates my scheduling through FurryESA.
Information to Be Used or Disclosed:
- The Emotional Support Animal letter ("Letter") prepared by the Licensed Mental Health Professional, if applicable.
- All medical or mental health records and information related to the Letter or evaluation by the Licensed Mental Health Professional. This includes, without limitation, all relevant information, opinions, diagnoses, assessments, notes (excluding psychotherapy notes), and documentation related to such assessments, treatments, and the Letter, including any pre-screening or demographic information provided to FurryESA by me.
- Other personal information, including my name, address, telephone number, gender, and date of birth.
Purpose of Disclosure:
I request that this information be disclosed for any purpose deemed necessary or advisable by FurryESA.
Authorization to Disclose Information:
I hereby authorize FurryESA and my Licensed Mental Health Professional to disclose the information outlined above.
Methods of Disclosure:
I authorize my information to be exchanged between FurryESA and the Licensed Mental Health Professional electronically, via telephone, facsimile, or through any other means deemed appropriate by FurryESA or the Licensed Mental Health Professional. I also authorize FurryESA to include my information in a database to facilitate efficient access to my information by FurryESA and the Licensed Mental Health Professional.
Redisclosure:
I acknowledge that once my information is disclosed by the Licensed Mental Health Professional to FurryESA, FurryESA may further disclose it. If my information is disclosed to or received by an individual or entity that is not subject to state or federal privacy laws, my information may no longer be protected.
Revocation of Authorization:
I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance on this authorization, or as permitted by law, including the right of FurryESA to contest a claim or the policy itself. To revoke this authorization, I must send a written request to the Licensed Mental Health Professional, as outlined in their notice of privacy practices, and to FurryESA. I understand that my revocation will not affect any disclosures made prior to the date of revocation.
Effect of Refusal to Sign:
I understand that signing this authorization is voluntary. FurryESA will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.
Expiration and Additional Provisions:
This authorization will remain valid until revoked in writing by me or as otherwise provided by law, whichever occurs first. A copy of this authorization is as valid as the original. I understand that I am entitled to receive a copy of this authorization.