This HIPAA Release and Authorization allows the patient to request the disclosure of either their complete medical record or specific records (excluding photos) from Cheeky Medspa, and to specify the recipient, purpose of release, and preferred format (paper pick-up, mailed copy, or email—with acknowledgment of risks and non-HIPAA-compliant email). The patient must provide identifying information, recipient details, and an expiration date for the authorization (not to exceed 30 days). The patient acknowledges that signing is voluntary, that they may revoke the authorization in writing, and that disclosed information may be re-shared by the recipient and lose HIPAA protection. The patient also understands that they may be responsible for printing, postage, and processing fees, and that record preparation may take up to 60 business days.
Once the form is completed, it needs to be emailed to info@alaskacheeky.com and we will confirm receipt and notify them when completed.