HIPAA Authorization for Use or Disclosure of Protected Health Information

Patient first name

Patient last name

Date of birth

Month

Day

Year

Date

1. Provider(s) Releasing Information

Healthcare providers

Healing Thyme Concierge Nursing LLC

All protected health information (PHI), including but not limited to records related to:

Coordination of concierge nursing services, referrals, treatment, payment, and follow-up care in Connecticut.

Verbal, written, electronic, mail, fax, or secure portal.

This authorization expires

On a specific date (1 year from signature)

When care ends

Never (revokable anytime)

Specific expiration date

• I can revoke in writing anytime (doesn't apply retroactively)

Patient signature

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