Consent Forms

HIPAA DISCLOSURE AUTHORIZATION FORM

Full Name_____________________________________________________________

I hereby authorize Cynthia "Cindy" Scott, LMT#122542, BCTMB, CLT, CPMT, COMT, to use or disclose my protected health information related to Massage Therapy to the following persons:

______________________________________________________________________

name relation phone number

______________________________________________________________________

name relation phone number

______________________________________________________________________

name relation phone number

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that, at any time, this authorization may be revoked. I understand that my health care will not be affected if I refuse to sign this form.

I understand that no personal/medical information will be released to any third party without disclosure authorization.

______________________________________________________________________

Signature Date

EXPIRATION DATE: This authorization will expire on the last day of December of each year.