Health Information Authorization

Patient Name*
Date of Birth*
Date of Request*

As required by the HIPAA Privacy Regulations, KoreMe Anti-aging and Aesthetics Group LLC may not use or disclose your protected health information without your authorization.

1. I hereby authorize KoreMe Anti-aging and Aesthetics Group LLC or any of its employees to use or disclose my Patient Health Information to the following person(s), entity (ies), or business associated with this office:

2. Patient Health information authorized to be disclosed:

Lab Work, medical history, physical examinations, diagnoses on therapies, telemedicine encounters, and tele-health encounters.

3. For the specific purpose of:

Bio-identical hormone therapy, Andropause Treatment, Menopause Treatment, and Hormone Deficiency Treatment.

4. I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.

5. Unless otherwise revoked, this Authorization will expire on:

6. I understand that I have the right to:

  1. Revoke this authorization by sending written notice to KoreMe Anti-aging and Aesthetics Group LLC and that revocation will not apply to information that has already been released in response to this authorization.
  2. Inspect a copy of Patient Health information being used or disclosed under federal law.
  3. Refuse to sign this authorization.
  4. Receive a copy of this authorization.
  5. Restrict what is disclosed with this authorization.

7. I understand that my refusal to sign this document will not affect my treatment, payment, and enrollment in a health plan, or eligibility for benefits merely because I do not provide authorization to use or disclose protected patient health information.

8. By signing below, I understand and acknowledge that:

  1. I have read and understand this Authorization.
  2. If I have questions about disclosure of my protected information, I may contact Dr. DiSanto at KoreMe Anti-aging and Aesthetics Group LLC at the phone number below.

Patient Signature*