HIPPA Authorization for Use or Disclosure of Health Information

Sunny Skies Healthcare Integrative Psychiatry & Medicine

Patient Name

Date of Birth

I authorize Sunny Skies Healthcare to communicate with, release information to, and obtain records and information from:

Name

Phone

Fax

Address

Relationship with the Patient

Purpose of Release:

The purpose of this disclosure of information is to share treatment information and to coordinate care.

If another purpose, please specify:

In the event of a disclosure necessary for emergency notification, Sunny Skies Healthcare, Inc. will disclose.

Information to be Disclosed:

Completed

Medical/Psychiatri/Medication

Assesments Progress Notes

Lab Reports

Treatment Plan/Treatments Plans

Reviews Discharge Summaries

TMS Treatments

Other:

Revocation:

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Sunny Skies Healthcare Records Department. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

This authorization will expire on the following. Date

If I do not specify an expiration date, this authorization will expire one year after the patient's participation in treatment ends.

Conditions :

I understand that if I don't sign this authorization, the consequence will be that no information will be shared. Sunny Skies Healthcare, the information to be released.

Form of Disclosure:

We reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, Sunny Skies Healthcare, Inc. does not use encryption technology for e-mail and therefore, information being transmitted via email may be viewed by unauthorized persons during transmission.

I understand that it may be impossible to determine whether unauthorized access to e-mail has taken place. Additionally, email usage may be monitored by Sunny Skies Healthcare administration for internal security purposes.

Redisclosure:

Federal and State law prohibit the person or organization to whom disclosure is made from making any further disclosure of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2 and all applicable state confidentiality laws.

Patient Name

Date

Signature of Parent, Guardian or Personal Representative:

Date

Witness Signature:

Date

THIS FORM MEETS ALL REQUIREMENTS OF 42 CFR PART 2, ALL APPLICABLE STATE CONFIDENTIALITY LAWS, AND 45 CFR PARTS 160 & 164 (HIPAA)

805 W. Randolph St. Suite 202 Chicago, IL 60607 | Phone: 312-526-3500 | Fax: 312-291-9126 | brainsway@sunnyskieshealthcare.com |

Your information will be encrypted.