Authorization to release patient information

Name of patient*

First Name

Last Name

Date of birth*

I hereby authorize Dr. Yacoub MD Inc., also known as Brain Health USA, to release and disclose my medical records and related information in accordance with applicable legal requirements. To

Name of Organization or individual *

Email of organization/ individual*

List more if there's any.

Signature*

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I, the undersigned, hereby grant authorization to Ehab Yacoub MD inc. to disclose my personal information to the organization or individual specified above. I acknowledge that I have thoroughly read and comprehended this authorization form, and that my signature is a voluntary act of conscious consent prior to the disclosure of any records or information. I understand that I retain the right to abstain from signing this form, and that if I choose not to do so, the aforementioned organization or individual will not have access to my information. Unless otherwise revoked, this consent shall remain in effect for one year from the date of execution. A reproduction of this authorization form, whether in paper or electronic form, shall be considered as valid as the original and is available upon request.

Signature of patient/parent/authorized representative*

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Probation on redisclosure: this information has been disclosed to you from records whose confidentiality is protected by federal law, federal regulation, (42 CFR, Part 2) Probation from making any further disclosure of this information with specific written consent of the person to whom it pertains. A general authorization for release of medical or other information if held by another part not sufficient for this purpose, federal regulation state that any person who violated any provision of this law shall be fined not more than $500 in case of the first offense, not more than $5000 in case of each subsequent offense.