Age / Gender: {radio-3} / {radio-3}
Primary Care Physician:
Referring Physician:

Clinical Concerns:
Current Symptoms:
Current Treatment:
Current Medication:

Thermogram Hx:
Results of clinical correlation:
Surgical Hx:
Dental Hx:
General Hx:
Family Hx:
Diagnoses:
Skin Lesions Or Physical Abnormalities:

(Female Patient Only)
Ob/ Gyn Hx:
Mammogram/ Ultrasound Hx:
Notes:

As required by the Privacy Regulations, Thermography Rio Grande Valley, LLC, 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:

EMI, Electronic Medical Interpretation:
Patient Health InformatIon authorized to be disclosed: Thermal images and related health history

For the specific purpose of (describe in detail): Interpretation of said images

Effective dates for this authorization:
Today's date: 10/22/2024 .This authorizatIon will expire at the end of 10 days.

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:

1. Revoke this authorizatIon by sending written notice to this office and that revocation will not affect this office’s previous reliance in the use or disclosure pursuant to this authorization.
2. Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization.
3. Inspect a copy of Patient’s Health Information being used or disclosed under federal law.
4. Refuse to sign this authorization.
5. Receive a copy of this authorization.
6. Restrict what is disclosed with this authorization.

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

{name-1-first-name} {name-1-last-name}

10/22/2024