Scroll Top

Authorization Use of PHI

Authorization for Use and Disclosure of Personal Health Information

This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. section 1320d, et seq., and regulations promulgated there under, as amended from time to time (collectively referred to as “HIPAA”).

This authorization affects your rights in the privacy of your personal healthcare information. Please read it carefully before signing.

Viking Alternative Medicine, LLC will not condition treatment, payment, enrollment in a health plan, or eligibility for benefits as applicable, on you providing authorization for the requested use or disclosure.

YOU MAY REFUSE TO SIGN THIS AUTHORIZATION.

By signing this authorization, you acknowledge and agree that Viking Alternative Medicine may use or disclose your personal healthcare information for the purpose(s) of treatment, payment and operation at Viking Alternative Medicine, LLC.

By signing this authorization, you agree that Viking Alternative Medicine, LLC may disclose your personal healthcare information to those recipients who need it for treatment, payment, and/or operations.

Further by signing this authorization you acknowledge that you have been provided access to a copy of and understand Viking Alternative Medicine, LLC’s Privacy Notice containing a complete description of your rights, and the permitted uses and copies of the Privacy Notice as amended are available from Viking Alternative Medicine, LLC at any of its offices or by sending a written request with return address to:

132 CHESTERFIELD TOWNE CENTER
CHESTERFIELD, MO 63005

In accordance with your rights under, and subject to certain restrictions imposed by HIPAA, you may inspect or copy your PHI in the designated record set maintained by Viking Alternative Medicine, LLC for as long as the PHI is maintained in the designated record set.

You have the right to revoke this authorization, in writing, at any time, except to the extent that Viking Alternative Medicine, LLC has taken action in reliance on it. A revocation is effective upon receipt by Viking Alternative Medicine, LLC of a written request to revoke and a copy of the executed authorization form to be revoked at the address listed above.

authorization shall expire upon the earlier occurrence of:

  • revocation of the authorization,
  • a finding by the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights that this authorization is not in compliance with requirements of HIPAA
  • Complete satisfaction of the purposes for which this authorization was originally obtained, to be determined in the reasonable discretion of Viking Alternative Medicine, LLC, or
  • Six years from the date this authorization was executed.

By signing his authorization, you acknowledge and agree that any information unused or disclosed pursuant to this authorization could be at risk for re-disclosure by the recipient and no longer protected under HIPAA.

Viking Alternative Medicine, LLC will provide you a copy of this signed authorization as requested.

I have read and fully understand the information presented in this release form concerning HIPAA.

Name
MM slash DD slash YYYY