HIPAA Authorization to Release Health Information

I authorize __________________________________ (my “Healthcare Provider”) to disclose health information to DPT Associates, LLC d/b/a Chrysalis (“Chrysalis”), which has a 12-week, post-operative program designed to help anyone undergoing breast surgery thrive during their recovery by providing exercises, nutritional guidance, and support (the “Chrysalis Method”).

The information that may be disclosed includes: name, email, phone number, date of surgery, type of surgery, any surgery precautions, and any other information necessary to determine whether the Chrysalis Method is appropriate for me.

The purpose of this authorization is to allow my Healthcare Provider to disclose healthcare information to Chrysalis to determine whether the Chrysalis Method is appropriate for me.

This Authorization will expire when I no longer participate in the Chrysalis Method program.

I understand that I do not have to sign this Authorization, but if I do not, then I may not be enrolled in the Chrysalis Method. Failure to sign this Authorization will not affect medical treatment I might receive from my Healthcare Provider.

I understand that I may change my mind and revoke (take back) this Authorization at any time, except to the extent that my Healthcare Provider has already acted based on this Authorization. To revoke this Authorization, I must write to my Healthcare Provider at their address.

I understand that my Healthcare Provider may be required by Federal privacy laws (such as the HIPAA Privacy Rule) to protect my health information. By signing this document, I authorize my Healthcare Provider to use and/or disclose (release) my health information for the purposes described above.

I understand that those persons who receive my health information may not be required by Federal privacy laws to protect it and may share my information with others without my permission, if permitted by laws governing them.

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(Signature of individual)                                                                        Date signed


(Printed name of individual)

Please check the appropriate box on the sign-up form indicating your electronic signature for authorization and acknowledgement of this form. Please sign and print a copy of this form for your own records.