HIPAA Privacy Authorization Form **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)** **

1.Authorization I authorize_____SPEAKMD LLC___________________________________(Healthcare Providers) to use and disclose the protected health information described below

2.Effective Period  This authorization for release of information covers the period of healthcare from: a.Specific Document Only

3.Extent of Authorization** I authorize the release of my specific uploaded health record only. No further records are released.

HIPAA Waiver

This form allows your specific medical document to be translated. The form indicates you have released the right of sharing this document with medical professionals in order to translate the document. The document cannot be shared with third parties and this document is the only record to be used.