HIPAA / CONSENT FOR DISCLOSURE OF INFORMATION
By my signature below, I hereby authorize JustScripts and it’s and it’s agents and affiliates to disclose my individually identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus ("HIV") and Acquired Immune Deficiency Syndrome ("AIDS"), mental illness (except for psychotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form.
I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non- healthcare provider; the released information may no longer be protected by federal and state privacy regulations.
I understand I will be responsible for calling in my own refills unless I contract Just Scripts to do so on my behalf. I agree to print and sign all documents and understand JustScripts will obtain doctors signatures and return these and any other requested information factually and in a timely manner. I also understand that the approval process cannot begin until JustScripts receives all documents requested.
I understand that this authorization will expire by law 180 days from the date of this authorization unless I otherwise specify. I desire this authorization to be in effect until (Expiration date/event). I further understand that I may revoke this authorization at any time by notifying this practice in writing. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation wiII not affect any actions taken before the receipt of the written revocation.