HIPPA Medical Release


HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT  INFORMATION PURSUANT TO 45 CFR 164.508  

 

 

         

I authorize and request the disclosure of my medical information for the purpose of review and evaluation in connection with the use of Hyperbaric Oxygen Therapy.  

The information should be released to the General Manager at Hyperbaric Health, located at 2605 Virginia Beach Blvd #105, Virginia Beach,  VA 23452. With the email of scott@hyperbarichealth.io (HIPAA-compliant email). 

All information relating to my medical records (as needed) for purpose of evaluating mild hyperbaric oxygen therapy.  

I understand the following: See CFR §164.508(c)(2)(i-iii) 

  1. I have a right to revoke this authorization in writing at any time, except to the extent that information has been released based on this authorization.  
  2. The information released in response to this authorization may be re-disclosed to other parties.  
  3. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.  

 

 

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Signed by Scott Aadal
Signed On: July 8, 2024


Signature Certificate
Document name: HIPPA Medical Release
lock iconUnique Document ID: 6a094065a7921f2f077db90f8a28ab9e9e328b87
Timestamp Audit
April 2, 2024 4:14 pm EDTHIPPA Medical Release Uploaded by Scott Aadal - scott@hyperbarichealth.io IP 72.212.175.189