Give or Decline HIPAA Authorization and Continue to Main Screen

    Authorization for the Use or Disclosure of Health Information from LeBlanc Consulting

    Please fill out all fields that apply to continue.

    Completion of this document authorizes the use and disclosure of health information about you. Failure to provide all the information requested may invalidate this Authorization.
    I understand that LeBlanc Consulting is required to maintain and safeguard the privacy and security of my information under applicable federal, state, and local health information privacy rules that govern the use and disclosure of my information, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended from time to time.
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    By agreeing to this HIPAA Authorization, I hereby authorize LeBlanc Consulting to use and disclose, within and among LeBlanc Consulting entities, such as my regional care team and service provider group, and to other third parties as specified for the purposes listed below, the contact information that I have provided to leblancconsulting.com (my name, mailing and email addresses, telephone number, and, as appropriate, Social Security Number) so that LeBlanc Consulting may use and disclose my information for the following purposes:

    Select the record you authorize to be disclosed or select ‘Decline’ below:
    • To use or disclose to third-party vendors my information to send me marketing communications to promote items and services that LeBlanc Consulting believes may be of value to me, even if unrelated to my direct care or benefits.

    As required by applicable law, this Authorization lasts for one (1) year unless I revoke it.

    I understand that I have the right to revoke this Authorization at any time by navigating to Profile and Preferences or Data Sharing & Authorizations on the LeBlanc Consulting website or mobile application, and following the instructions provided. LeBlanc Consulting will stop using or disclosing my information for these purposes upon receipt of my revocation. However, my revocation will not affect any actions already taken in reliance on this Authorization.

    I understand that once information is used or disclosed under this Authorization, there is a potential for it to be re-disclosed and may no longer be protected under federal or state privacy law. However, some state laws may restrict further disclosures unless I provide additional authorization or unless otherwise permitted or required by law.

    I understand that I have the right to receive a copy of this Authorization by navigating to the leblancconsulting.com website or mobile application and selecting the HIPAA Authorization link located at the bottom of the home page.

    LeBlanc Consulting will not condition my treatment, payment, or eligibility for services or benefits on whether I agree to this Authorization electronically or on paper.

    Signature AcknowledgmentBy clicking and typing your name below, you acknowledge that you have read and agree to the terms of this Authorization.
    I have read and agree to the terms of this Authorization for the use and disclosure of my information by LeBlanc Consulting.