HIPAA Release of Information

SOCIAL MEDIA AUTHORIZATION FORM

I,______________________________________________ ____hereby authorize Dr. R Thomas Kellogg and his affiliates, employees and agents to publish the following personal health information / story: _____________________________________________________________ (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name and other personally identifiable information) on Facebook and/or rtkelloggdmd.com.

The following information about me will not be disclosed: health/dental history, date of birth, address, phone number, social security number, etc.  Only my name, photo/video, and treatment described above will be disclosed and only with my permission.

I understand that any personal health information or other information released via the social media platform(s) above may be subject to re-disclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.

This authorization is valid from the date of my signature below and does not expire.

I understand that I have a right to revoke this authorization by providing written notice to Dr. Kellogg’s office. However, this authorization may not be revoked if Dr. Kellogg’s office, its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.

Name of Member: __________________________________________

Signature of Member: _______________________________________

Date:______________________________