HIPAA Form H004-2010.1

Patient Authorization for Release of Medical Records for Continuity of Care

All Fields Are Required

I, or my authorized representative, request that health information regarding my care and treatment be released as specified on this form. In accordance with the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. §1320d et seq. (“HIPAA”) and the Health Information Technology for Economic and Clinical Health Act of 2009 (“HITECH”), I authorize the below providers to coordinate care, and release and disclose my entire medical record including but not limited to:


To/From: Mindstrong Health Services, 303 Bryant Street, Mountain View, CA, 94041 AND 
Patient Ping Health Network Entities (to provide Mindstrong with notification if you are hospitalized), AND
PROVIDER
ADDRESS

The above information may be used for the following purposes:

This authorization is fully understood and is made voluntarily on my part. I understand that my healthcare provider may not condition treatment or payment upon execution of this authorization. However, if I refuse to sign this authorization, then my healthcare provider may not be able to obtain my medical information. I understand that the information may be redisclosed by the recipient and may no longer be protected by law. I hereby release my above listed healthcare provider and any of their HIPAA Business Associates involved in collecting my records from any legal liability that may arise out of the collection, gathering, scanning, digitizing, and release of the information requested. By signing below I express my intent to be bound by this authorization. I understand that I may revoke this authorization at any time except to the extent that action based on this authorization has been taken. Cancellation of this authorization must be made in writing and faxed to (650) 352-2080. I understand that if I wish to review the Notice of Privacy Practices I may request a copy by contacting the telephone number below and one will be provided to me at no cost.

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Date Signed: