Miiskin – Telehealth Authorization
Authorization for disclosure of information to health care providers
Agreeing to this form authorizes the disclosure of information about me to my associated health care providers.
I hereby authorize Miiskin to disclose my name, email, phone number, patient identification number, demographic information and images to my health care providers at the clinic with which my account is associated so that my health care providers can use this information for my treatment and care coordination.
This Authorization is valid for as long as I am eligible to receive services from Miiskin or one year, whichever is shorter. I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Miiskin. I understand that my health care providers are required by HIPAA and/or state law to protect my information; however, Miiskin may be required by law to state that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by federal or state law. I understand that I have the right to inspect or copy the health information to be used or disclosed as permitted under federal or state law and receive a copy of this Authorization. I understand that Miiskin does not provide treatment, assessment, diagnosis, or any medical services but may be required by law to state it will not condition my treatment on whether I provide authorization for the requested use or disclosure. I have the right to refuse to sign this Authorization; however, Miiskin will not disclose my information to my clinic or health care providers unless I sign this Authorization unless such disclosure is otherwise permitted by law.
By clicking the box, I acknowledge that I have read and authorize the disclosure of my information by Miiskin for the purpose described in this Authorization. If I am the parent or personal representative of the individual whose information will be disclosed, by clicking the box, I confirm I have the authority to agree to the terms of this Authorization on behalf of the individual.
Updated: June 25th 2021.
