Authorization to Release and Use Health Information
Last Updated: March 31, 2022
By clicking “I agree,” I am providing my authorization for the health care provider (“Provider”) scanning this QR code to disclose the protected health information described below to Cutera, Inc. and its affiliates (“Cutera”) for the purposes listed.
- I hereby authorize the release of my name and treatment information, (the “Health Information”) to Cutera.
- The purpose of this authorization is to authorize Cutera to use the Health Information to provide me with services that are ancillary to the health care services I receive from Provider in addition to allowing Cutera to contact me regarding my treatment experience (the “Purposes”).
- This authorization is in effect until I revoke it.
- I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to email@example.com. The revocation will be effective immediately upon Cutera’s receipt of my written notice, except that the revocation will not affect any uses or disclosures that were already made by a Provider to Cutera prior to receipt of the written notice of revocation.
- I understand that the Cutera will only use this information for the Purposes and it will not disclose to any third parties, other than service providers that may assist Cutera in fulfilling the Purposes.
- I understand that if the person or entity that receives my Health Information is not required to comply with the applicable privacy regulations, then the Health Information described above may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Rule.
- I am agreeing to this authorization voluntarily and I understand that my treatment may not be conditioned upon my agreeing to this authorization, and that I may refuse to agree to this authorization.
- I understand that I can receive a copy of this authorization by contacting firstname.lastname@example.org.