Surescripts Authorization

Effective date: February 1, 2022


I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:

In accordance with Law in Patient’s State of Residence and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

  1. Lyn Health Practice Group uses SureScripts, Inc., a prescription system that allows prescriptions and related information to be exchanged between my providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs I am currently taking and/or have taken in the past. This information will be utilized by Lyn Health Practice Group in accordance with my clinical care plan.

  2. This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment, and/or confidential HIV related information by SureScripts, Inc. to Lyn Health Practice Group

  3. I have the right to revoke this authorization at any time by writing to Lyn Health Practice Group via email at privacy@lynhealth.io. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

  4. Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

  5. Information disclosed under this authorization might be re-disclosed by the recipient, and this re-disclosure may no longer be protected by state or federal law.

  6. THIS AUTHORIZATION DOES NOT AUTHORIZE LYN HEALTH PRACTICE GROUP TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THOSE PERMITTED UNDER APPLICABLE LAW.