(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
I authorize Project Belle LLC to use and disclose the protected health information described below to the parties I list thereafter to favorably impact my health and wellbeing. Those relevant parties include: Belle employees and agents, my family members, caregivers, medical professionals, medical groups, health systems and health insurance companies.
This authorization for release of information covers all past, present and future periods.
Extent of Authorization
I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) as well as any audio, video or photographic material.
This medical information may be used by the organization I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
This authorization shall be in force and effect until July 17, 2021, at which time this authorization expires.
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.