Contract analysis

Section 1. Identity of the Individual Authorizing Disclosure I, Jonathan Robert Caldwell, born March 14, 1956, currently residing at 418 East 72nd Street, Apt. 14A, New York, New York 10021, Social Security Number ending in XXX-XX-4781, hereby execute this Authorization for Disclosure of Protected Health Information (this "Authorization") pursuant to the Health Insurance Portability and Accountability Act of 1996, as

Section 2. Persons and Entities Authorized to Disclose Protected Health Information This Authorization is directed to any and all health care providers, health plans, health care clearinghouses, hospitals, medical centers, clinics, physicians, surgeons, internists, specialists, pharmacies, laboratories, diagnostic imaging centers, rehabilitation facilities, nursing facilities, home health agencies, hospice providers,

Section 3. Persons Authorized to Receive Protected Health Information The following named individuals are authorized to receive, inspect, obtain copies of, review, and discuss the Authorizing Party's PHI with any covered entity to which this Authorization is directed. Each authorized recipient is identified by full legal name, relationship to the Authorizing Party, date of birth, and current address for purposes of i

Section 4. Description of Protected Health Information to Be Disclosed The Authorizing Party hereby authorizes the disclosure of any and all protected health information, without limitation as to time period, condition, or category, including but not limited to the following: (a) Medical records, charts, clinical notes, and histories. All medical records in any form, including but not limited to physician's office re

Section 5. Purpose of the Disclosure The disclosure of PHI pursuant to this Authorization is authorized for the following purposes: (a) Participation in health care decisions. To enable the authorized persons identified in Section 3 above to participate in health care decisions on behalf of the Authorizing Party, including but not limited to decisions relating to medical treatment, surgical procedures, diagnostic tes

Section 6. Effective Date, Expiration, and Duration Effective Date. This Authorization shall become effective on April 1, 2023. Expiration and Duration. This Authorization shall remain in full force and effect until revoked in writing by the Authorizing Party in accordance with Section 7 below, or until the death of the Authorizing Party, whichever first occurs; provided, however, that this Authorization shall surviv

Section 7. Right to Revoke The Authorizing Party has the right to revoke this Authorization at any time by providing written notice to the covered entity or entities from which disclosure is sought. Any such revocation must comply with the following requirements: (a) Written notice required. Revocation of this Authorization must be in writing. Oral revocations shall not be effective. (b) Signature required. The writt

Section 8. Redisclosure Notice NOTICE REGARDING REDISCLOSURE: The Authorizing Party acknowledges and understands that protected health information disclosed pursuant to this Authorization may be subject to redisclosure by the authorized recipients identified in Section 3 above, and that once PHI has been disclosed to such recipients, it may no longer be protected by HIPAA or the HIPAA Privacy Rule (45 C.F.R. Part 164

Section 9. Acknowledgment and Understanding The Authorizing Party acknowledges, represents, and confirms each of the following: (a) Understanding of Authorization. The Authorizing Party has carefully read this Authorization in its entirety and understands its contents, including the nature and scope of the PHI authorized to be disclosed, the identities of the persons authorized to receive such PHI, and the purposes f

Section 10. Execution 10.1 Authorizing Party AUTHORIZING PARTY: By: ________ Name: Jonathan Robert Caldwell Date: April 1, 2023 10.2 Witness Attestation We, the undersigned witnesses, each being at least eighteen (18) years of age and of sound mind, hereby attest that we were present and witnessed the execution of this Authorization by Jonathan Robert Caldwell on the date set forth below. We observed the Authorizing

Section 11. Notary Acknowledgment ACKNOWLEDGMENT STATE OF NEW YORK COUNTY OF NEW YORK On this 1st day of April, 2023, before me, the undersigned, a Notary Public in and for the State of New York, personally appeared Jonathan Robert Caldwell, known to me (or proved to me on the basis of satisfactory evidence) to be the individual whose name is subscribed to the within instrument, and acknowledged to me that he execute