RELEASE & HIPPA CONSENT

Authorization for Use or Disclosure of Protected Health Information (Required by the health Insurance Portability and Accountability Act, 45 C.F.R Parts 160 & 164) 

1. Authorization-I authorize this health care provider to use and disclose the protected health information as described above only for purposes of treatment & continued care performed at VIDA Aesthetics LLC. 

2. Effective period-This authorization for release of information covers the period of healthcare for all past, present, and future periods. 

You agree and warrant that the individual signing is agreeing to the terms and policies of this agreement on your behalf. You agree that the information provided is completely valid, has legal effect, is is enforceable, and is binding on and non-refutable by you.