PROCLE Release Consent Form
If I am a Patient I acknowledge and agree to the following:
Authorization to Release Information
I hereby authorize the release of my protected health information that I provide through the PROCLE HEALTHWORKS program, including, but not limited to my demographic information, my symptoms, my health information as well as my images to the healthcare providers using the PROCLE HEALTHWORKS program. I hereby authorize PROCLE HEALTHWORKS to use and disclose such information as permitted by State and Federal Laws and for the purposes of treatment, share clinical information for education and to provide preventive care. I acknowledge and agree that I am waiving my privacy rights by submitting such information to PROCLE HEALTHWORKS and this information may be redisclosed. I understand and acknowledge that I may revoke the authorization by providing written notice to PROCLE HEALTHWORKS at 3555 Montwood Ct., Marietta, GA 30062 or email ProCleHealthworks.firstname.lastname@example.org, but the revocation only applies after the written revocation is received by PROCLE HEALTHWORKS. This authorization to use the information submitted shall last for so long as I maintain an account with PROCLE HEALTHWORKS and for two years thereafter.
I acknowledge and agree that I am personally responsible for the security and privacy of my username and password to access PROCLE HEALTHWORKS.
I hereby acknowledge and agree that I am over the age of 18 and voluntarily using the PROCLE HEALTHWORKS program for my own personal purposes.