HIPAA Authorization

Cabot Medical, PLLC · Grosse Pointe, Michigan

Confidential: Protected Health Information. Complies with 45 CFR 164.508.

Please review this authorization in full. Your consent and electronic signature will be collected in the following step.

I authorize any physician, healthcare professional, hospital, clinic, laboratory, pharmacy, insurer, or other entity holding my health information to disclose the records indicated below to Cabot Medical, PLLC for the purpose of treatment and care coordination.

Records authorized for disclosure:

• Complete health records
• Medical examination records
• Medical history obtained through telehealth, telemedicine, video, audio, asynchronous patient portal messaging
• Immunization record
• Laboratory results / imaging (X-ray) reports

I understand that the information disclosed may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV), and may include information about behavioral or mental health services and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time by submitting a written revocation to Cabot Medical, PLLC, except to the extent that action has already been taken in reliance on it.

Unless revoked earlier, this authorization expires 365 days from the date of signature.

I understand that authorizing this disclosure is voluntary, that I may refuse to sign, and that I need not sign in order to receive treatment.

I understand that I may inspect or copy the information to be disclosed, as provided in 45 CFR 164.524, and that information disclosed under this authorization may be subject to re-disclosure by the recipient and may then no longer be protected by federal confidentiality rules.