However, without this Authorization, my Dr. Chantel Imran may, within its discretion, withhold from disclosure any of the above information as permitted or required by law.Īccess to treatment or services may not be denied to me if I decline to sign this Authorization or revoke my Authorization. Chantel Imran has received about me from other healthcare practices, providers or facilities. Chantel Imran may disclose any information or records (within the scope of the authorization) that Dr. I acknowledge that with this authorization Dr. I acknowledge that such healthcare information may include information regarding mental health screenings and/or treatment, including psychotherapy notes HIV/AIDS, infectious disease, sexually transmitted infection testing, screening, diagnosis, and/or treatment genetic testing history of domestic violence, child abuse, and/or family abuse and, substance/ alcohol use and treatment history. I acknowledge that such healthcare information may include the following: x rays, clinical diagnosis, histories of present illnesses, immunizations, allergies, prescription drug information, laboratory results, diagnostic screening and testing, clinical procedures, medical research, clinical trials, billing, account, and insurance information. Chantel Imran to release any and all healthcare information about me to my HealthLynked personal health record (PHR) for my own uses and purposes. Healthlynked Authorization Release of Information
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