HIPAA Release Form

(6.19.23)

I give my permission for Dr. Patrick Angelo and Beyond Inflammation to share health information listed in this document and agree to the terms specified within.

Health Information and Personal Data
I give the above organization permission to use the following:
-Health record information including, but not limited to, lab test results, medications and current conditions.
-My experience in Beyond Inflammation program, including, but not limited to, text exchanges and correspondence with BI personnel, as well as results such as weight loss, waistline reduction and other biometric data.

Authorization Details
All health information will be de-identified to protect my privacy, unless needed to ensure proper and safe health consultation and medical treatment. I understand that I am permitted to revoke this authorization to share my non-aggregated health data at any time and can do so by submitting a request in writing to Beyond Inflammation.