Authorization to Share Health Information

My 4M Life

Authorization for Use and Disclosure of Protected Health Information

HIPAA-Compliant Authorization (45 CFR § 164.508)

This Authorization permits the use and/or disclosure of protected health information ("PHI") as described below. Please complete every section. An incomplete form is not a valid Authorization.

Section 1 — Patient Information

Patient Name: _________________________________________________________________

Date of Birth: _________________________________________________________________

Address: _________________________________________________________________

Phone: _________________________________________________________________

Email: _________________________________________________________________

Section 2 — Person/Entity Authorized to Disclose PHI

Authorize My 4M Life and the following provider(s)/entity(ies) to disclose PHI:

Name of Disclosing Person/Entity: _________________________________________________________________

Address: _________________________________________________________________

Phone / Fax / Email: _________________________________________________________________

Section 3 — Person/Entity Authorized to Receive PHI

Name of Recipient: _________________________________________________________________

Relationship to Patient (if any): _________________________________________________________________

Address: _________________________________________________________________

Phone / Fax / Email: _________________________________________________________________

Section 4 — Specific Information to Be Used or Disclosed

Check all that apply and complete date ranges where requested:

☐ Complete medical record

☐ Office / progress notes — Date range: _____________________

☐ Laboratory results — Date range: _____________________

☐ Imaging / radiology reports — Date range: _____________________

☐ Medication list / prescription history

☐ Wellness, lifestyle, and longevity assessments

☐ Genetic, genomic, or biomarker test results

☐ Mental health records (excluding psychotherapy notes)

☐ Psychotherapy notes (separate authorization required by law — initial here: ____)

☐ Substance use disorder records (subject to 42 CFR Part 2 — initial here: ____)

☐ HIV/AIDS-related information (initial here: ____)

☐ Communicable disease information (initial here: ____)

☐ Billing or payment records

☐ Other (describe): __________________________________________________

Section 5 — Purpose of the Use or Disclosure

Indicate the purpose. If the disclosure is at the patient's request, you may write “at my request.”

☐ Continuing care / new provider

☐ Personal use

☐ Legal matter

☐ Insurance / reimbursement

☐ Employer / disability / FMLA

☐ Research

☐ Other: ____________________________________________________________

Section 6 — Expiration

This Authorization will expire upon the earlier of:

Specific date: _________________________________________________________________

Specific event (e.g., “close of legal matter”): _________________________________________________________________

If no expiration is provided, this Authorization expires one (1) year from the date of signature.

Section 7 — Your Rights

A. Right to Revoke

You have the right to revoke this Authorization at any time by submitting a written revocation to My 4M Life's Privacy Officer at the address listed in our Notice of Privacy Practices. Revocation will not apply to information that has already been used or disclosed in reliance on this Authorization.

B. Conditioning of Treatment

We may not condition your treatment, payment, enrollment in a health plan, or eligibility for benefits on whether you sign this Authorization, except as permitted under 45 CFR § 164.508(b)(4) (e.g., research-related treatment, or services created solely for the purpose of disclosure to a third party).

C. Potential for Re-disclosure

Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. Special protections may continue to apply to substance use disorder records (42 CFR Part 2), HIV/AIDS, mental health, and genetic information under federal or state law.

D. Right to a Copy

You are entitled to a copy of this signed Authorization.

Section 8 — Signature

____________________________________ ____________________________________

Patient Signature Date

____________________________________ ____________________________________

Printed Name Date of Birth

If signed by a personal representative, complete the following:

____________________________________ ____________________________________

Personal Representative Signature Date

Printed Name and Authority to Act (e.g., parent, guardian, healthcare POA): _________________________________________________________________

Office Use Only

Received By: _________________________________________________________________

Date Received: _________________________________________________________________

Action Taken / Records Released On: _________________________________________________________________