To authorize Health Pals to obtain your medical information from your existing provider, please click the link below:
HIPAA Form
The Health Pals Company, LLC (Health Pals) provides healthcare services to the general public. Patients may register for an account with Health Pals either online or in person. By creating an account with Health Pals, you authorize the use or disclosure of your protected health information as described below:
- You authorize all of your prescribers, caregivers, and other personnel involved in your care to provide us with the totality of your health history
- Information that may be disclosed may encompass the entirety of your health history (past, present, and future). All time periods of your heath information may be shared.
- Health Pals is authorized to acquire this information starting on the day you register, and ending on the day you terminate your membership with Health Pals.
- You understand that the information provided to Health Pals may be subject to re-disclosure to either a healthcare provider or caregiver that is directly involved in your care; but only on a need to know basis. For example, Health Pals employees may discuss your health history with a Physician (MD) for the purpose of dispensing your medications.
- Health Pals does not share your medical history with law enforcement unless served with a warrant, subpoena, court order, or other legally demanding document.
- You have the right to revoke this authorization at any time by cancelling your membership via any of the following means:
- In Writing: 1100 Historic 66 West, Waynesville, MO 65583
- By Phone: 877.928.9748
- You understand that any action taken in reliance on this authorization cannot be reversed, and that revoking your authorization will not affect those actions.
