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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 device /implant information for the purpose of review and evaluation in connection with the use of Hyperbaric Oxygen Therapy. And my implant pressure rating and serial number.

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 device or implants for purpose of evaluating mild hyperbaric oxygen therapy.

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

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.
The information released in response to this authorization may be re-disclosed to other parties.
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: April 2, 2024

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April 2, 2024 4:14 pm EDT

HIPPA Medical Release Uploaded by Scott Aadal - scott@hyperbarichealth.io IP 68.228.131.102