HIPAA Forms – Club Beauty

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HIPAA AUTHORIZATION

In compliance with Club Beauty Privacy Practices, this form will allow you to designate an individual(s) to whom Club Beauty may disclose your protected health information. This may include individually identifiable information related to past, present, or future appointments, and medical or financial information. This does not include information relating to mental health treatment or HIV test results as releasing that information requires your separate written consent. If you do not want to designate an individual(s) to receive your protected health information, indicate “none” below.

Patient Name *

Email *

Date of Birth//

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone Number: *

I do hereby authorize Club Beauty to disclose protected health information to the following:

1. Name *

1. Relationship to patient *

1. Telephone number *

2. Name *

2. Relationship to patient *

2. Telephone number *

3. Name *

3. Relationship to patient *

3. Telephone number *

By signing below, I acknowledge that I have had full opportunity to read and consider the content of this authorization and understand that my protected health information may be disclosed to the individual(s) listed above. I understand that designating the individual(s) listed above does not exclude Club Beauty from disclosing my protected health information as outlined by Club Beauty’s Privacy Practices, (a copy will be provided upon request). I understand that I have the option to revoke this authorization at any time, and then execute a new authorization. I also understand that unless revoked in writing by completing a new authorization form, this authorization will remain in effect until I choose to revoke it.

Patient Signature

Date //

Personal Representative (Relationship to patient)

Date //

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HIPAA AUTHORIZATION

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