a HIPAA ont Health Insurance Portability and Accountability Act HIPAA is @ US lew designed to provide privacy standards to protect patients’ medical records and other health \edormation. ‘This means that if you requite mecical assistance while in the US, and Smaller Earth ask your healthcare provider for medical information in order to assist you, by lax, the request for your information would not be granted, under any ‘orcumstances. ‘This document provides the abilty for healthcare providers to shave information with Smoiler Earth so that we c@n assist you By completing this form, you give consent to Smalier Earth, your parents or guardian, and your physicians and/or ‘You alse consent to Smaller Earth utilizing other medical providers to discuss yout medical and/or insurance issues ‘any such material as necessary in treating any mecical consition rat may arse: You also:give consent that Smaver Earth may notify your emergency contact listed in his application of any situation thatwe deem to be an emergency. This authorization s valid for two years from the date signed. 1 circumstances can Smaller Earth release medical information trom your pitysician or provider of service fo formation hes been disclosed to us by your physician or provider of service, and we sovider of service for your Und you or anyone. Yout medical inf are prohibited by federal law from further cisclosute. Please contact yout physician or pi medical information | give Smaller Earth permission to release any ot all ofthe following information as appropriate inthe event of @ medical condition. SS tit ET. ar rancelend ce tormaton eed mesa sc inant Steno and Aton Inia: ETT 5 Nome, date ot service, total charge total paid and dete of payment. Firs Insurance iD eumber andor social securty numbet. pinePatersName False Was Thea Susser 9°" fep ouanaoon 12/AVG/ 144 Home aaceess: J.-M. re Sewers #4, Adalloletpe Malcos Hicisclesmer Palmer Signature of the Patio we pute sine: 25 02/20 eee etic [INSPIRE PEOPLE TO GO FURTHER