NOTICE: HIPAA AUTHORIZATION REQUIRED TO USE THIS FORM. SIGNATURE FIELD BELOW.

HIPAA AUTHORIZATION. To the extent information in this form is protected health information under the Health Insurance Portability and Accountability Act, as amended, and its regulations (“HIPAA”), I authorize the use and disclosure of such information in accordance with this HIPAA AUTHORIZATION. I authorize the use and disclosure of all of the information that I have entered into this form (“Information”). I am the individual whose Information is included in this form or I am the personal representative of that individual. The purpose of this disclosure is to allow communication of the Information to a the medical practice from whose website I obtained this form. The Information will be disclosed to Dermatologists Of Central States and/or its information technology contractors (“Recipients”) in order to facilitate communication between me and the medical practice. I understand that I have the right to revoke this Authorization at any time prior to my submission of this form by simply not signing this Authorization, but once I sign this Authorization and submit the form, the Information will be disclosed to Recipients in reliance upon my Authorization. I understand that I am not required to sign this Authorization and that any medical practice making this form available on its website may not condition my treatment on whether I use this form to communicate with the medical practice. This Authorization has no expiration date.  I understand that the Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipients and will no longer be protected by HIPAA. I hereby acknowledge that I may print a copy of this Authorization for my records.
TYPE YOUR FULL NAME BELOW AS SIGNATURE AND AUTHORIZATION*