OPTIMIZEMD, LLC D/B/A DEXAFIT CINCINNATI HIPAA AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Name of Patient:_________________
Date of Birth: ___________________
Phone Number: _________________
I, the Patient described above (“Patient”) authorize OptimizeMD, LLC d/b/a DexaFit Cincinnati (“Practice”) to disclose personal health information about me to DexaFit, Inc. (“DexaFit) the company that assists Practice in the preparation of the detailed report as well as provides Practice with certain administrative and marketing support including hosting its website for the purpose of:
Improving the functionality of the DexaScan device, services and reporting information and research and/or to determine my qualifications for approved clinical studies and to potentially serve as a research candidate.
Creating marketing and educational materials, including press releases, news stories, websites, publications, which may include both photographs or video clips for both internal purposes and for disclosure to external media.
The personal health information about me may include my: name, treatment modality, age, duration of treatment, treatment plan, diagnosis, city and state of residence, photographs, the fact that I was treated at the DexaFit Cincinnati location using DexaFit, Inc.’s technology and services, and information about my life and how I discovered Practice and engaged them for treatment.
I understand the provision of health care treatment, and payment for my health care are not dependent on this authorization. I understand that I am not required to sign this authorization. The information will not be used or disclosed without this authorization. I understand any information used or disclosed pursuant to this authorization may be subject to redisclosure.
I understand I have the right to revoke this authorization in writing, except to the extent information has already been released pursuant to this authorization at the time of revocation. I can revoke this authorization by sending correspondence to Practice at the following address: 8784 Montgomery Rd. #102, Cincinnati, OH 45236.
I hereby release, discharge and agree to hold Practice and DexaFit, Inc. harmless from any liability that may arise from the release of information authorized above.
This authorization shall expire 10 years from the date of signature.
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Patient Signature or Legal Representative
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Date of Signature
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Printed Name Relationship to Patient (if applicable) If Patient is a minor or has a personal representative, I represent that I am the legal parent/guardian/personal representative of the Patient name above and I am not prohibited by Court Order from releasing access to the requested information.