Living Springs Natural Health (LSNH) & Living Springs Health & Wellness (LSHW), PLLC are members under the:

TURTLE ISLAND PROVIDER NETWORK Licensed & Registered by: Tribal Health Programs & Clinics

A Private Tribal Membership Facility NOT OPEN TO THE PUBLIC

Authorization to Use or Disclose Protected Health Information

Client Name: Type Name: Last, First Middle Date: Select Today’s Date
Date of Birth: Select D.O.B. Age: Age Gender: Gender
Home Address: Enter Street Address City: Enter City State: Enter State Zip: Enter Zip

As required by the Privacy Regulations, Living Springs Natural Health may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:

Physicians Insight, LLC
Patient Health Information authorized to be disclosed: Thermal images and related health history

For the specific purpose of: Interpretation of said images

Effective dates for this authorization: ___________________through ______________________________
This authorization will expire at the end of the above period.

I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control. I understand I have the right to:

Revoke this authorization by sending written notice to this office and that revocation will not affect this office’s previous reliance on the uses or disclosure pursuant to this authorization.

Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization.

Inspect a copy of Patient Health Information being used or disclosed under federal law.

Refuse to sign this authorization.

Receive a copy of this authorization.

Restrict what is disclosed with this authorization.

I also understand that if I do not sign this document, it will not affect the condition of my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.

☐ I understand, agree & provide my consent that the submission of this form electronically requires the use of a digital signature. By signing, I agree that my digital signature on this form has the same legal affect as my manual signature (in accordance with the ESIGN Act).

Date: Click to Select a Date.

E-SIGN Your Name Here
Patient Signature	Authorized Signature of Facility	Date