PHI

Patient Authorization for Use and Disclosure of Protected Health Information
By signing, I authorize My Home Telemed to use and/or disclose certain protected health information
(PHI) about me to

This authorization permits My Home Telemed to use and/or disclose the following individually
identifiable health information about me (specifically describe the information to be used or disclosed,
such as date(s) of services, type of services, level of detail to be released, origin of information, etc.):
The information will be used or disclosed for the following purpose:
(If disclosure is requested by the patient, purpose may be listed as “at the request of the individual.”)
The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the
information. This authorization will expire in writing at my request.
The Practice will will not _X_ receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.
I do not have to sign this authorization in order to receive treatment from My Home Telemed. In fact, I
have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to
this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the
federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent
that the practice has acted in reliance upon this authorization. My written revocation must be submitted to
the privacy officer at:

My Home Telemed LLC

Signed by: