I authorize: To use and disclose a copy of the specific health information described below:
✓ History and physical examinations✓ Consultation reports✓ Laboratory reports✓ Operative reports✓ Discharge summary✓ X-ray/Diagnostic images✓ Other, specify below.
To: Dr. Manuel PeraltaAttn: Wilfredo García Reyes Encarnaciónstreet 5. CECILIP. República Dominicana.Phone (+1) 809 920 8989
If the information to be disclosed contains any of the types of records or information listed below, additional laws regarding the use and disclosure of the information may apply. I understand and accept that this information will be disclosed, so I will proceed to fill in the following fields with my data as a sign of agreement.
This authorization is voluntary and you may refuse to sign this authorization. Refusal to sign this authorization will affect your ability to participate in this care coordination program and failure to disclose any of the above conditions may result in cancellation of the surgery.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any use or disclosure that has already been made with your permission cannot be undone.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal law. However, I also understand that federal or state law may restrict the release of HIV/AIDS information, mental health information, drug/alcohol diagnosis, treatment, or referral information.
I understand that my health information may be shared with health care providers, nurse case managers, health advocates, and other professionals who have currently been or will be involved in my care in order to better coordinate my care.
I have read this authorization and I understand it. Unless revoked, this authorization does not expire.
I declare that the information I will provide is accurate and complete about me.
PLEASE USE THE GUIDELINES BELOW TO ENSURE THAT THE PHOTOS YOU SUBMIT ARE ACCEPTED BY ALL OUR DOCTORS AND SERVICE PROVIDERS.
BREAST SURGERY PHOTOS:
For clients requesting any type of Breast Surgery, the following additional requirements are needed for our surgeons to make a more informed decision on suitability as a candidate for surgery.
The front view includes the neck, shoulders, breasts, and navel.
Front view with both arms raised above the head.
Front view with both arms raised above the head, body leaning or slightly bent forward assuming a diving position.
Left and Right Side view with both arms down the side, as if standing to attention.
Left and Right Side view with both arms raised above the head, body leaning forward or slightly bent forward assuming a diving position.
FACIAL PHOTOS MUST INCLUDE:
Head Tilted Backwards
Head Tilted Downwards
RHINOPLASTY PHOTOS MUST INCLUDE:
TUMMY TUCK PHOTOS MUST INCLUDE:
THIGH LIFT PHOTOS MUST INCLUDE:
Left Profile – Showing Inside Thigh
Right Profile – Showing Inside Thigh
Left Profile – Showing Outside Thigh
Right Profile – Showing Outside Thigh
ARM PHOTOS MUST INCLUDE:
Left Arm Raised At Side Of Body
Right Arm Raised At Side Of Body
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