HIPAA Privacy Authorization

Use this form to authorize PMC Psychedelic Medicine Centers of America to use or disclose your protected health information in specific ways permitted under the Health Insurance Portability and Accountability Act (HIPAA). This authorization is voluntary, and you may revoke it at any time by submitting a written request to our practice coordinator.

This authorization is intended to permit a specific disclosure of your protected health information — for example, sharing records with another healthcare provider, allowing a family member to discuss your treatment with our team, or releasing information for a referral, insurance, or legal matter.

You do not need to complete this form just to receive treatment at PMC. The information we routinely use and share to treat you, run our practice, and bill for your care is governed by our Privacy Policy and does not require a separate authorization.

If you have questions about whether this form applies to your situation, please call our practice coordinator before completing it.

Complete the form below and submit it electronically. Our team will confirm receipt and follow up with any questions.

For a complete description of your rights under HIPAA — including how we may use and disclose your protected health information without your authorization for treatment, payment, and healthcare operations — please see our Privacy Policy, which serves as our Notice of Privacy Practices.