[vc_empty_space height="32px"]
In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Blue Moon Senior Counseling will not release confidential information, in person or by telephone, email or fax to any unauthorized people. When returning phone calls, we will not leave a message on an answering machine or voicemail without written consent. Information may not be given to an unauthorized person who may answer your phone. If you would like to authorize us to release medical information to someone other than yourself or to leave information on a recording device, please specify below. I understand and authorize Blue Moon Senior Counseling and any of its affiliates/subsidiaries to release confidential health information pertaining to my care by the following methods and to the following people. I understand that it is my responsibility to notify Blue Moon Senior Counseling if the authorization information changes.
I consent to Blue Moon Senior Counseling and any of it's affiliates/subsidiaries being able to leave messages for me on my: [vc_empty_space height="32px"] I consent to Blue Moon Senior Counseling and any of it's affiliates/subsidiaries to share confidential information regarding my care to:
[vc_empty_space height="32px"]
I authorize this information to be disclosed in the following ways:
[vc_empty_space height="32px"]
Specific description of the Protected Health Information that I authorize for disclosure: [vc_empty_space height="32px"]
I give specific authorization for the following to request disclosures of my health information: [vc_empty_space height="32px"]
This authorization is valid, unless a specific expiration date or event is specified here: [vc_empty_space height="32px"] I understand I may revoke this authorization at any time in writing. I am entitled to make a copy of, or request to receive a copy of this authorization. I acknowledge by my signature below that I have read and understand this authorization, it accurately reflects my wishes, and a photocopy, facsimile, or other electronic copy is as valid as the signed original.
