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HIPAA PRIVACY AUTHORIZATION FORM

Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act (“HIPAA”) — 45 CFR Parts 160 and 164)

I ____________________ (DOB: · Last 4 digits of SSN: ), hereby authorize all medical service sources and healthcare providers to use and/or disclose the protected health information (“PHI”) described below to Cortexia Health, Inc., a Delaware corporation, for the purpose of completing a Co-Diagnosis or for the purpose of translating my PHI for use by healthcare providers or for the purpose of storing my PHI. And I hereby authorize Cortexia Health, Inc., to use and disclose all PHI to healthcare providers and other medical service sources for the purpose of completing a Co-Diagnosis or other service offered by Cortexia Health, or for the purpose of translating my PHI for use by healthcare providers.
I hereby request the information to be released to Cortexia Health at the following address:
Cortexia Health, Inc.
1825 S Grant St, Ste. 200
San Mateo, CA 94402
Tel: 650-770-5313
I hereby authorize the release of PHI as follows: a. My complete health record (including records relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse); OR b. My complete health record with the exception of the following information (check as appropriate): Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Other (please specify):
This authorization for release of PHI covers the period of healthcare (check one): all past, present, and future periods; OR from (date) to (date) .
This authorization shall be in force and effect for 2 years from the date of signing.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

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What are you most unsure about right now?

HIPAA PRIVACY AUTHORIZATION FORM

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