HIPAA Release Form

Adapted from HIPAA Journal - Release Form
https://www.hipaajournal.com/wp-content/uploads/2017/09/HIPAA-Journal-sample-HIPAA-release-form-v1.pdf"

HIPAA Release Form

Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.

Section 1

give my permission for First Person Solutions LLC, makers of CelWel, to share the information listed in Section II of this document with the person(s) or organziation(s) I have specified in Section IV of this document.

Section II - Health Information

I would like to give the above organization permission to disclose my health information as provided during the course of the CelWel Lyme Study.

This includes the information provided in the organization's Lyme Study Patient Registration process, the first Health Symptoms Questionnaire that should be completed before starting CelWel, and the the second Health Symptoms Questionnaire t that should be competed after taking CelWel.

Form of Disclosure

Electronic copy or access via a web-based portal
Hard copy

Section III - Reason for Disclosure

Please detail the reasons why information is being shared. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write ‘at my request’

The reason for disclosure is participate in the organization's CelWel Lyme Study.

I understand that I will be providing my name, date of birth, email, address, and other identifying information.

I have assured that this information and the results of both Health Symptoms Questionaiires will be only provided to those identified in Section IV below.

I have also been assured that this information will be securely anonymized if shared with others outside of this study.

Other reasons for disclosure

Section IV - Who Can Receive My Health Information

I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s):

First Person Solutions LLC (makers of CelWel)
1167 W. Baltimore Pike, Suite 237
Media, PA 19063 U.S.A.

Other individual(s) or organization(s)

I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.

Section V – Duration of Authorization

This authorization to share my health information is valid:

Duration of Authorization

(a) All past, present, and future periods
(b) From [Start Date] to [End Date] stated below
(c) The date of the signature in Section VI until the following event stated below

Start Date for choice (b) above

End Date for choice (b) above

Description of event for choice (c) above

I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:

First Person Solutions LLC (makers of CelWel)
1167 W. Baltimore Pike, Suite 237
Media, PA 19063 USA

I understand that:

• In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.

• I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in Section IV.

Section VI – Signature

I agree Terms and Conditions for this HIPAA Release Form

If this form is being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:

Name of person signing HIPAA Release

Describe below how this person has legal authority to sign this form