Divergence Consent to Examination and Treatment
HIPAA Authorization for Records Release
Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
1. Authorization. I authorize the above listed health care provider / business entity to use and disclose the protected health information described below to Divergence Physical Therapy and Wellness.
2. Effective Period. This authorization for release of information covers all past, present, and future periods of health care.
3. Extent of Authorization. I authorize the release of my complete health record with the exception of the following information: mental health records, communicable diseases (including HIV and AIDS), alcohol/drug abuse treatment.
4. Use. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
5. Termination. This authorization shall be in force and effect until I am discharged from Physical Therapy services, at which time this authorization form expires.
6. Revocation Rights. 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.
7. Benefits. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
8. Disclosure. 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.
Divergence HIPAA Authorization and Release Form
Releasing Health Care Provider / Business Entity
Health Care Provider Name: Mike DeMille, Connor Sheridan, Garrett Labberton
Business / Practice Name: Divergence Physical Therapy and Wellness
Address 330B Washington Street, Wellesley MA 02481