(HIPAA COMPLIANT: 45 CFR §164.508)

Name: _______________________________________________________

Soc. Sec. No.: _________________________________________________

Date of Birth: __________________________________________________

 1. Disclosure of Prescience Health, LLC. authorization from (45 CFR 164.508(C)(1)(ii)):
 2. Disclosure authorizes directors of Prescience Health, LLC., my lawyers, contracted providers and/or employees of Prescience
    Health, LLC. 45 CFR 164.508(C) (1) iii).
 3. Documentation for disclosure: My entire medical chart & patient account information, including but not limited to, (A) a copy of the
    entire chart, including the jacket thereof, (B) copies of any diagnostic materials including x-rays, MRI’s, CT scans, etc..., and the
    reports thereon, (C) correspondence, telephone messages or other documented notes, (D) Patient questionnaires or intake
    information forms, (E) medication lists, (F) office visit notes, sign-in forms, operative reports, consultation notes, lab results, (G)
    photographs of any kind, (H) charges for services and any payments thereon, including HCFA’s and any other billing information.
     45 CFR 164.508(C) (1) (I).
 4. Further, you authorized to provide “my attorneys” with office conferences, telephone conferences, and medical reports. You
    authorized to provide testimony at deposition or trial as requested by “my attorneys.” I understand and recognize that this
    Authorization shall operate to result in disclosure of otherwise confidential information related to sexually transmitted disease;
    acquired immunodeficiency syndrome; human immunodeficiency syndrome; substance abuse, addiction or treatment; as well as
    behavioral and/or mental health evaluations and information.
 5. Purpose for disclosure: For use by “my attorneys” in a civil action or as evidence in a legal claim or proceeding. 45 CFR
    164.508(C) (1)(iv).
 6. Expiration of this Authorization: Valid for a period of five (5) years from the date signed, unless earlier revoked in writing by me. 45
    CFR 164.508(C) (1) (v). I understand that I have the right to revoke this Authorization by way of delivering a signed and dated
    Revocation of Authorization to the healthcare provider named above, 45 CFR 164.508(C)(2)(i), but that this Authorization cannot
    be revoked as to Protected Health Information which has been previously released in reliance on this document. 45 CFR
 7. Re-Disclosure acknowledgment: Acknowledge awareness that once Protected Health Information has disclosed it may be re-
    disclosed by the recipient and no longer am subject to the protections of Federal law. 45 CFR 164.508(C) (2) (iii).
 8. Voluntaries: I voluntarily signed this Authorization and acknowledge I am aware that my refusal to sign this Authorization will not
    result in a denial of health care by any hospital or health care provider. This Authorization has not been coerced by any health
    care entity or any of its business associates. 45 CFR 164.508(C)(2)(ii).
 9. The Protected Health Information authorized for disclosure shall be provided to my attorneys within the time frames set forth in 45
    CFR 164.524(b)(2).

                     Any fax and/or copy of this Authorization shall be treated as an original document.

Signed:                                                            Date: ____________________________________________

Printed name: _____________________________________                Date of Birth: ______________________________________

                           Prescience Health, LLC. | 340 Ramapo Valley Road Oakland NJ 07436
                 | | 800-959-2541

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