As required by the Privacy Regulations, Northwest Medical Thermography may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.
I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:
EMI, Electronic Medical Interpretations
Patient Health Information authorized to be disclosed: Thermal Images and related health history
For the specific purpose of (describe in detail)
Interpretation of said images
Authorization will expire one year from date signed
I understand I have the right to:
1. Revoke this authorization by sending written notice to this office and that revocation will not affect this office’s previous reliance on the uses or disclosure pursuant to this authorization.
2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as are result of this authorization.
3. Inspect a copy of Patient Health Information being used or disclosed under federal law.
4. Refuse to sign this authorization.
5. Receive a copy of this authorization.
6. Restrict what is disclosed with this authorization.
I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.