Authorization for the Disclosure of Health Information Under HIPAA

Recipients of My Information: By signing below, I consent to the licensed mental health professional, along with their staff and representatives (collectively referred to as “Licensed Mental Health Professional”), sharing my health information as detailed below with Wellness Wag. Furthermore, I permit Wellness Wag to disclose the health information I provide to them to the licensed mental health professional with whom Wellness Wag coordinates my scheduling.

Information to Be Used or Disclosed:

1. The Emotional Support Animal letter (the “Letter”) prepared by the Licensed Mental Health Professional, if applicable;
2. All records and medical or mental health information related to the Letter or the evaluation conducted by the Licensed Mental Health Professional. This includes, but is not limited to, all information, opinions, diagnoses, assessments, notes (excluding psychotherapy notes), and documentation pertaining to the assessment, treatment, and the Letter, including any pre-screening or demographic information I provided to Wellness Wag; and
3. Other personal details about me, such as my name, address, phone number, gender, and date of birth.

Purpose of Disclosure: I am requesting the disclosure of this information for any purpose deemed necessary or appropriate by Wellness Wag.

Authorized Disclosures: I hereby authorize both Wellness Wag and my Licensed Mental Health Professional to disclose my information as outlined above.

Methods of Disclosure: I consent to my information being exchanged between Wellness Wag and the Licensed Mental Health Professional electronically, by phone, fax, or any other method deemed appropriate by Wellness Wag or the Licensed Mental Health Professional. I also permit Wellness Wag to store my information in a database to facilitate more efficient access by Wellness Wag and the Licensed Mental Health Professional.

Re-disclosure: I acknowledge that once my information is disclosed to Wellness Wag by the Licensed Mental Health Professional, Wellness Wag may re-disclose it. If my information is shared with or received by an individual or entity not governed by state or federal privacy laws, it may no longer be protected.

Revoking Authorization: I may revoke this authorization at any time, except to the extent that action has already been taken based on this authorization or if other laws permit Wellness Wag to contest a claim under the policy or the policy itself. To revoke this authorization, I must send a written request to the Licensed Mental Health Professional as specified in their notice of privacy practices, and to Wellness Wag. I understand that my revocation will not affect any disclosures made before the date my permission is withdrawn.

Effect of Refusal to Sign: I understand that signing this authorization is voluntary. Wellness Wag will not condition my treatment, payment, enrollment, or eligibility for benefits on my signing this authorization.

Expiration and Other Provisions: This authorization will remain valid until revoked by me in writing or as provided by law, whichever occurs first. A copy of this authorization will be as valid as the original. I understand that I am entitled to receive a copy of this authorization.