Common use of Disclosure and Use of Protected Health Information Clause in Contracts

Disclosure and Use of Protected Health Information. I, , hereby authorize the disclosure of my protected health information by Xxxx Xxxxxxxxxxxxx M.D. and Manhattan Internal Medicine, PLLC (together, for this purpose, the “Practice”) to Knoepflmacher CCPHP, LLC (the “Company”), a company with which the Practice works to help carry out Practice administrative and related functions, and to deliver certain Enhancements which are described in a Membership Agreement between me and the Company. I further authorize the disclosure of my protected health information by the Company as necessary to enable the Company to carry out those functions. For purposes of this document, protected health information means any and all information relating to healthcare services provided to me by the Practice including, but not limited to, information relating to healthcare services provided to me prior to this date and information received by the Practice in connection with my care. I understand that I am not required to electronically sign this authorization/consent in order to receive treatment, and I understand that information disclosed pursuant to this authorization/consent may be re-disclosed by the recipient and no longer protected by privacy regulations; although I understand that any Company re-disclosure is anticipated, unless otherwise required by law, to be for the limited purpose of carrying out the functions described above.

Disclosure and Use of Protected Health Information. I, , hereby authorize the disclosure of my protected health information by Xxxx Xxxxxxxxxxxxx M.D. Xxxxxxxx Xxxxx, D.O. and Manhattan Internal MedicineNewton Wellesley Ambulatory Services, PLLC Inc. (“NWAS”) (together, for this purpose, the “Practice”) to Knoepflmacher CCPHP, LLC Synergy Private Health (the “Company”), a company with which the Practice works to help carry out Practice administrative and related functions, and to deliver certain Enhancements which are described in a Membership Agreement between me and the Company. I further authorize the disclosure of my protected health information by the Company as necessary to enable the Company to carry out those functions. For purposes of this document, protected health information means any and all information relating to healthcare services provided to me by the Practice including, but not limited to, information relating to healthcare services provided to me prior to this date and information received by the Practice in connection with my care. I understand that I am not required to electronically sign this authorization/consent in order to receive treatment, and I understand that information disclosed pursuant to this authorization/consent may be re-disclosed by the recipient and no longer protected by privacy regulations; although I understand that any Company re-disclosure is anticipated, unless otherwise required by law, to be for the limited purpose of carrying out the functions described above.

Disclosure and Use of Protected Health Information. I, , hereby authorize the disclosure of my protected health information by Xxxx Xxxxxxxxxxxxx Xxxxxx Xxxxx, M.D. and Manhattan Internal MedicineXxxxxx Xxxxx, M.D., FACC, PLLC (together, for this purpose, the “Practice”) to Knoepflmacher Xxxxx CCPHP, LLC (the “Company”), a company with which the Practice works to help carry out Practice administrative and related functions, and to deliver certain Enhancements which are described in a Membership Agreement between me and the Company. I further authorize the disclosure of my protected health information by the Company as necessary to enable the Company to carry out those functions. For purposes of this document, protected health information means any and all information relating to healthcare services provided to me by the Practice including, but not limited to, information relating to healthcare services provided to me prior to this date and information received by the Practice in connection with my care. I understand that I am not required to electronically sign this authorization/consent in order to receive treatment, and I understand that information disclosed pursuant to this authorization/consent may be re-disclosed by the recipient and no longer protected by privacy regulations; although I understand that any Company re-disclosure is anticipated, unless otherwise required by law, to be for the limited purpose of carrying out the functions described above.

Disclosure and Use of Protected Health Information. I, , hereby authorize the disclosure of my protected health information by Xxxx Xxxxxxxxxxxxx M.D. Xxxxxx X. Xxxxxxxxxxx, M.D., F.A.C.P. and Manhattan Internal MedicineConcorde Medical Group, PLLC (together, for this purpose, the “Practice”) to Knoepflmacher Silvershein CCPHP, LLC (the “Company”), a company with which the Practice works to help carry out Practice administrative and related functions, and to deliver certain Enhancements which are described in a Membership Agreement between me and the Company. I further authorize the disclosure of my protected health information by the Company as necessary to enable the Company to carry out those functions. For purposes of this document, protected health information means any and all information relating to healthcare services provided to me by the Practice including, but not limited to, information relating to healthcare services provided to me prior to this date and information received by the Practice in connection with my care. I understand that I am not required to electronically sign this authorization/consent in order to receive treatment, and I understand that information disclosed pursuant to this authorization/consent may be re-disclosed by the recipient and no longer protected by privacy regulations; although I understand that any Company re-disclosure is anticipated, unless otherwise required by law, to be for the limited purpose of carrying out the functions described above.