I authorize Neuronetics to use or disclose Protected Health Information (“PHI”) as defined under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), of the Patient identified above, to Neuronetics for evaluating my candidacy for certain non-invasive mental health treatment options. More specifically, I understand that my treating health care provider has recommended, and I have agreed to, the use of the Neuronetics screening application, NeuroStar PHQ-10 Patient Survey, which follows Patient Health Questionnaire (PHQ)-10, a standardized screening tool for major depressive disorder (MDD). I authorize the release of my PHQ-10 score and responses to the PHQ-10 tool, along with limited demographic information about me, to Neuronetics for purposes of evaluating potential treatment options. I understand that the information released or disclosed pursuant to this authorization may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), alcohol and drug abuse, and mental health treatment and I authorize such disclosure for the purposes stated herein. This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records under 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived. I understand and further authorize Neuronetics to share my results with my treating healthcare provider and to incorporate my results into my electronic medical record maintained by or on behalf of my treating healthcare provider.
I understand that this authorization is voluntary and that I may refuse to sign. I further understand that my treating health care provider may not condition my treatment or eligibility for benefits on completion of this authorization.
I understand that this authorization is in effect for one (1) year or until I revoke this authorization. I understand that I may cancel or revoke my authorization at any time by writing to: email@example.com or 3222 Phoenixville Pike, Malvern, PA 19355. Revocation will be effective immediately upon receipt by Neuronetics, except to the extent that information was previously disclosed in reliance upon this authorization. If my PHI has already been shared, it may not be possible to recall it. I understand that if the person or entity receiving this information is not a health care provider or health plan covered under HIPAA or other federal privacy regulations, the information described in this authorization may be disclosed to other individuals or institutions and no longer protected by these regulations.
I have read this form and agree to the uses and disclosures of the PHI as described. I understand that refusing to sign this form does not stop disclosure of PHI that is otherwise permitted by law without my specific authorization or permission. By signing this authorization, I acknowledge that I have read the authorization and fully understand the terms contained herein. I understand that Neuronetics will provide me with a copy of this signed authorization.
I understand that if I am signing on behalf of a minor child, this authorization will expire upon the child reaching the age of 18, unless I provide proof of my legal guardianship over the child.