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HIPPA Release Authorization

Release Form

HIPAA Release Authorization

I, __________________________ hereby authorize Intravene Wellness Therapies, LLC (“Intravene”) and its duly authorized employees and agents, to publish the following personal health information, image, and/or story that contains my name or likeness:

_<<DESCRIPTION OF MEDIA – might be able to use “the attached” depending on circumstance>>___________ (the “PHI”).

This PHI may contain information relating to the diagnosis, treatment, and health care services provided or to be provided to me by Intravene and may identify my name and other personally identifiable information. This information may be used in print media, on the radio, TV, the Intravene website, and on social media (e.g. Instagram, Facebook, Twitter, TicToc).

The following information about me will not be disclosed if specifically stated here:

__________________________________________________________________________.

Unless earlier revoked, this authorization is valid for one year from the date listed below.

I understand that any personal health information or other information released via the social medial platforms above may be subject to re-disclosure by such social media platforms and may no longer be protected by applicable Federal and State privacy laws.

I understand that I have a right to revoke this authorization by providing written notice to Intravene. However, this authorization may not be revoked if Intravene, its employees or agents have taken action on this authorization prior to receiving my written notice.

I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to seek or receive treatment from Intravene, eligibility for benefits or enrollment or payment for or coverage of services.

I understand that I will not be compensated for the use of the PHI by Intravene. I also understand that Intravene and it’s duly authorized employees and agents are not liable to notify me or any creators of the PHI of its use of the PHI.

____________________________________

Signature, Date

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