Form Last Updated: 10/19/2023
I voluntarily request, consent to, and authorize the following parties (each, a “Disclosing Party”) to disclose my Health Information to Clara Medical Group, P.C., Innovative Medical Group FL, PLLC, Innovative Medical Group NY, PLLC, Innovative Medical Group NJ, LLC and/or any such other professional entities affiliated with the “Forward” healthcare offering (together with their successors and assigns, “Forward”) for the purposes of my care coordination and treatment by Forward:
(1) any medical professional from which I may request that my Health Information be retrieved; and (2) any medical professional to which Forward refers me.
For the purposes of this Authorization for Disclosure of Health Information (this “Authorization”), “Health Information” is defined as all of my health information that the Disclosing Party has in its possession, including information relating to any medical history, mental or physical condition and any treatment received by me. This Authorization does not extend to HIV test results, outpatient psychotherapy notes, substance use disorder treatment records, mental health records, or other types of sensitive health information that are afforded special protections by federal or state laws.
I authorize the Disclosing Party to send the Health Information released pursuant to this Authorization to Forward via email at [clinical@goforward.com]. Forward’s contact information is as follows:
Forward 660 4th St. #202 San Francisco, CA 94107 Telephone: 833-33G-OFWD Email: [clinical@goforward.com]
I request that this Authorization remain in effect until I notify the Disclosing Party that I am revoking or terminating this Authorization.
I understand that signing this Authorization is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment by Forward. If I change my mind, I understand that I can revoke this Authorization by providing a written notice of revocation to Forward at the address listed above. The revocation will be effective immediately upon Forward’s receipt of my written notice, except that the revocation will not have any effect on any action taken by Forward in reliance on this Authorization before it received my written notice of revocation.
I understand that I have a right to receive a copy of this Authorization upon request. A copy of this Authorization is as valid as the original.
I understand that Forward is required by federal law to inform me that the health information disclosed pursuant to this Authorization may be re-disclosed by the recipient and no longer protected by the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended from time to time (“HIPAA”). However, I understand that Forward will only use and share the PHI disclosed pursuant to this Authorization In support of healthcare services I receive from Forward and such Health Information will remain protected by HIPAA and used and disclosed as described in Forward’s Notice of Privacy Practices.
I understand that I may contact Forward for answers to my questions about the privacy of my health information. For more information about that, please refer to Forward’s Notice of Privacy Practices.
BY SIGNING OR INDICATING MY AGREEMENT ELECTRONICALLY, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND AND AGREE TO BE BOUND BY THIS AUTHORIZATION AND THAT I WILL ASK MY HEALTHCARE PROVIDER ANY QUESTIONS I HAVE.