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HIPAA Consent Statement

I understand that by completing and submitting this form, I may be providing protected health information (PHI). I authorize the receiving provider, laboratory, or organization to use and disclose my PHI for the purposes of treatment, payment, and healthcare operations, including contacting me regarding services, results, or follow-up care. I acknowledge that this authorization is voluntary, that I may revoke it at any time in writing, and that any revocation will not apply to information already used or disclosed. I also acknowledge that I have been offered access to the organization’s Notice of Privacy Practices.

I acknowledge that the T2YourHealth Privacy Policy has been made available to me for review. View Privacy Policy*

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I acknowledge that I have reviewed this HIPAA Consent Statement and that the T2YourHealth Privacy Policy has been made available to me.