tap item above the patient name icon launch the item to the left of the release of information item open the icon next to release of information item press the icon at the top left corner
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authorize Brown & Toland Physicians to release any and all healthcare information about me to my FollowMyHealth personal health record for my own uses and purposes. I acknowledge that such healthcare information may include the following: x-rays, clinical diagnosis, histories of present illnesses, immunizations, allergies, prescription drug information, laboratory results, diagnostic screening and testing, clinical procedures, medical research, clinical trials, billing, account, and insurance information.\r\n \r\nI acknowledge that such healthcare information may include information regarding mental health screenings and/or treatment, including psychotherapy notes;  HIV/AIDS, infectious disease, sexually transmitted infection testing, screening, diagnosis, and/or treatment; genetic testing; history of domestic violence, child abuse, and/or family abuse; and, substance/alcohol use and treatment history.\r\n\r\nI acknowledge that with this authorization Brown & Toland Physicians may disclose any information or records (within the scope of the authorization) that Brown & Toland Physicians has received about me from other healthcare Practices or facilities. Brown & Toland Physicians may, within its discretion, withhold from disclosure any of the above information as permitted or required by law. \r\n\r\nAccess to treatment or services may not be denied to me if I decline to sign this Authorization or revoke my Authorization. However, without this Authorization, my Practice will not electronically release my healthcare information to my FollowMyHealth personal health record. I may revoke this Authorization at any time.  Such revocation will promptly take effect except to the extent that Brown & Toland Physicians already has acted based on this Authorization.\r\n\r\nI may revoke this Authorization by removing Brown & Toland Physicians as a health care Practice with which I want to be connected on my FollowMyHealth account or providing my request to Brown & Toland Physicians.  However, I acknowledge that data previously submitted by Brown & Toland Physicians as authorized by me prior to my subsequent revocation of this Authorization will remain in my Follow My Health account. I understand that I may delete my FollowMyHealth account any time. \r\n\r\nThis authorization shall end upon the earliest of: a) the termination of the connection between my healthcare Practice and my FollowMyHealth Account; b) upon my written request submitted to support@followmyhealth.com; or c) 12 months from the date of execution of the Authorization.\r\n\r\n\tFor Authorized Representatives of Patients younger than 18 years old: This Authorization shall expire upon the earliest of:  (1)  the date the minor reaches the age of 18; or (2) the date FollowMyHealth receives written revocation from the minor, as an emancipated minor with legal authority to manage his/her own healthcare.\r\n\r\nI understand that the information submitted to my FollowMyHealth account is subject to the privacy and security protections of applicable Federal and State laws. I further understand and acknowledge that the manner in which FollowMyHealth protects my personal information is detailed in the FollowMyHealth Privacy Policy and the FollowMyHealth Terms of Use. \r\n\r\nI understand that Brown & Toland Physicians is not responsible for the security of data stored in the FollowMyHealth database, and that the owners of FollowMyHealth are responsible for ensuring the security of the data stored in FollowMyHealth. \r\n\r\nI have the right to receive a copy of this Authorization and may do so by clicking [Print] above. \r\n\r\n \r\nSigned on 01/28/2017 \r\n\r\nPlease complete the following information:\r\n\r\nLee, Laura \r\n\r\n02/13/1989 \r\n\r\n\r\nIf signing on behalf of a Patient, please complete the following:  \r\n\r\nRelationship to Patient: [Place \"x\" in the appropriate box below] \r\n\r\n[X]  Patient\r\n\r\n[ ]  Parent/Guardian/Other Legal Representative \r\n\r\nBy clicking [I ACCEPT], I acknowledge and agree to the terms of this 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I acknowledge that such healthcare information may include the following: x-rays, clinical diagnosis, histories of present illnesses, immunizations, allergies, prescription drug information, laboratory results, diagnostic screening and testing, clinical procedures, medical research, clinical trials, billing, account, and insurance information.\r\n \r\nI acknowledge that such healthcare information may include information regarding mental health screenings and/or treatment, including psychotherapy notes;  HIV/AIDS, infectious disease, sexually transmitted infection testing, screening, diagnosis, and/or treatment; genetic testing; history of domestic violence, child abuse, and/or family abuse; and, substance/alcohol use and treatment history.\r\n\r\nI acknowledge that with this authorization Brown & Toland Physicians may disclose any information or records (within the scope of the authorization) that Brown & Toland Physicians has received about me from other healthcare Practices or facilities. Brown & Toland Physicians may, within its discretion, withhold from disclosure any of the above information as permitted or required by law. \r\n\r\nAccess to treatment or services may not be denied to me if I decline to sign this Authorization or revoke my Authorization. However, without this Authorization, my Practice will not electronically release my healthcare information to my FollowMyHealth personal health record. I may revoke this Authorization at any time.  Such revocation will promptly take effect except to the extent that Brown & Toland Physicians already has acted based on this Authorization.\r\n\r\nI may revoke this Authorization by removing Brown & Toland Physicians as a health care Practice with which I want to be connected on my FollowMyHealth account or providing my request to Brown & Toland Physicians.  However, I acknowledge that data previously submitted by Brown & Toland Physicians as authorized by me prior to my subsequent revocation of this Authorization will remain in my Follow My Health account. I understand that I may delete my FollowMyHealth account any time. \r\n\r\nThis authorization shall end upon the earliest of: a) the termination of the connection between my healthcare Practice and my FollowMyHealth Account; b) upon my written request submitted to support@followmyhealth.com; or c) 12 months from the date of execution of the Authorization.\r\n\r\n\tFor Authorized Representatives of Patients younger than 18 years old: This Authorization shall expire upon the earliest of:  (1)  the date the minor reaches the age of 18; or (2) the date FollowMyHealth receives written revocation from the minor, as an emancipated minor with legal authority to manage his/her own healthcare.\r\n\r\nI understand that the information submitted to my FollowMyHealth account is subject to the privacy and security protections of applicable Federal and State laws. I further understand and acknowledge that the manner in which FollowMyHealth protects my personal information is detailed in the FollowMyHealth Privacy Policy and the FollowMyHealth Terms of Use. \r\n\r\nI understand that Brown & Toland Physicians is not responsible for the security of data stored in the FollowMyHealth database, and that the owners of FollowMyHealth are responsible for ensuring the security of the data stored in FollowMyHealth. \r\n\r\nI have the right to receive a copy of this Authorization and may do so by clicking [Print] above. \r\n\r\n \r\nSigned on 01/28/2017 \r\n\r\nPlease complete the following information:\r\n\r\nLee, Laura \r\n\r\n02/13/1989 \r\n\r\n\r\nIf signing on behalf of a Patient, please complete the following:  \r\n\r\nRelationship to Patient: [Place \"x\" in the appropriate box below] \r\n\r\n[X]  Patient\r\n\r\n[ ]  Parent/Guardian/Other Legal Representative \r\n\r\nBy clicking [I ACCEPT], I acknowledge and agree to the terms of this Authorization.", "resource-id": "com.jardogs.fmhmobile:id/textview", "ancestors": ["android.widget.TextView", "android.view.View", "java.lang.Object"], "clickable": false, "class": "android.support.v7.widget.AppCompatTextView", "bounds": [28, 1069, 1412, 2392], "componentLabel": "Text"}], "ancestors": ["android.view.ViewGroup", "android.view.View", "java.lang.Object"], "clickable": true, "class": "android.widget.LinearLayout", "bounds": [28, 956, 1412, 2392], "componentLabel": "List Item"}]}