HIPAA-COMPLIANT PATIENT AUTHORIZATION FORM

The following entity is authorized to use and disclose your protected health information:

Universal Medical Travel
United States
Email: Info@UniversalMedicalTravel.com | Phone: +1 (772) 494 1971 | WhatsApp: +1 (864) 842 1077

RECIPIENTS OF YOUR PROTECTED HEALTH INFORMATION

Your protected health information may be disclosed to and received from the following categories of recipients:

1. Internationally accredited hospitals, clinics, surgical centers, and healthcare facilities partnered with Universal Medical Travel to which you have been referred for evaluation and treatment;
2. Licensed physicians, surgeons, specialists, anesthesiologists, and other medical providers affiliated with the selected healthcare facility;
3. Administrative and clinical staff of the selected healthcare facility involved in the coordination of your care; and
4. Any other providers or facilities necessary for the evaluation, planning, and delivery of your requested medical procedure.

DESCRIPTION OF PROTECTED HEALTH INFORMATION TO BE USED OR DISCLOSED

This authorization covers the use and disclosure of your protected health information (PHI), including but not limited to:

5. Complete medical history, diagnoses, and clinical notes;
6. Laboratory and pathology reports and test results;
7. Imaging reports, X rays, MRI, CT scans, and other diagnostic materials;
8. Surgical history and operative reports;
9. Current and past medication lists, allergy information, and drug interaction records;
10. Treatment plans, procedure quotes, discharge summaries, and post operative instructions;
11. Pre operative evaluation results and physical examination findings;
12. Photographs submitted for cosmetic or surgical evaluation purposes;
13. Implant or medical device information (where applicable);
14. Rehabilitation and physical therapy protocols and follow up care instructions; and
15. Any other health information submitted through the Patient Information Form or provided separately by the patient or their treating physician.

PURPOSE OF USE AND DISCLOSURE

Universal Medical Travel is authorized to use and disclose the above described protected health information for the following purposes:

IMPORTANT: Items 4 and 5 below specifically authorize the healthcare facility to disclose your post treatment records to Universal Medical Travel. This explicit consent satisfies the requirements of international data protection laws, including the Swiss Federal Act on Data Protection (revDSG) and the European General Data Protection Regulation (GDPR).

16. Disclosure to Healthcare Facility: To forward your medical records and health information to the selected international healthcare facility and medical providers for the purpose of evaluating your medical condition, developing a recommended treatment plan, providing a procedure quote, and facilitating the scheduling and coordination of your requested medical procedure abroad.
17. Receipt from Healthcare Facility: To receive your protected health information, including treatment plans, procedure quotes, operative reports, discharge summaries, medication lists, clinical updates, and follow up care instructions, from the selected healthcare facility and medical providers for the purposes of professional case management, care coordination, post treatment follow up, and documentation.
18. Ongoing Case Management: To use your protected health information to coordinate all aspects of your medical tourism experience, including pre treatment planning, travel and logistics coordination, post procedure follow up, and continuity of care upon your return home.
19. Express Authorization for Reverse Disclosure from Healthcare Facility: I hereby expressly and explicitly authorize the selected healthcare facility, hospital, clinic, or medical provider to disclose and transmit to Universal Medical Travel my post treatment protected health information, including but not limited to my complete treatment plan, operative and procedure reports, anesthesia records, discharge summaries, medication and prescription lists, implant or medical device information, follow up care instructions, rehabilitation protocols, laboratory and pathology results obtained during treatment, and any other clinical documentation related to my procedure and recovery. This authorization is directed specifically at the healthcare facility and constitutes my explicit consent for the facility to share these records with Universal Medical Travel for the purposes of professional case management, continuity of care coordination, post treatment follow up, and documentation. I understand that this authorization satisfies the requirements of applicable data protection laws, including but not limited to HIPAA, revDSG, GDPR, and any other applicable national or international privacy law governing the healthcare facility’s disclosure obligations.
20. Acknowledgment of International Data Protection Laws: I understand that the healthcare facility to which I have been referred may be located outside the United States and may be subject to its own national or regional data protection laws, including revDSG or GDPR. I acknowledge that these laws may impose additional requirements on the facility before it may disclose my medical records to Universal Medical Travel. By signing this form, I expressly consent to such disclosure and authorize the healthcare facility to rely on this signed authorization as a valid legal basis for disclosing my post treatment records to Universal Medical Travel, to the extent permitted by applicable local law. If the facility determines that additional or facility specific consent is required under its local data protection law, I agree to sign any such additional consent form presented to me by the facility prior to my procedure.

YOUR RIGHTS UNDER THIS AUTHORIZATION

7.1 Right to Revoke
You have the right to revoke this authorization at any time by sending a written email request to Info@UniversalMedicalTravel.com. Revocation requests submitted by phone, WhatsApp, or any other means will not be accepted or processed. Once you have submitted your revocation email, you may contact our agency by phone at +1 (772) 494 1971 or by WhatsApp at +1 (864) 842 1077 solely to confirm that your email was received. Your revocation will take effect upon our receipt of your written email notice. Revocation will not affect any actions already taken prior to receiving your revocation.

7.2 Right to Refuse to Sign
You are not required to sign this authorization. Signing is entirely voluntary. However, if you choose not to authorize the use and disclosure of your protected health information, Universal Medical Travel will be unable to forward your medical records to the healthcare facility of your choice or receive clinical updates on your behalf, and we will therefore be unable to facilitate your medical tourism services.

7.3 Right to a Copy of This Authorization
You have the right to receive a copy of this signed authorization form. To request a copy, contact Universal Medical Travel at Info@UniversalMedicalTravel.com, call +1 (772) 494 1971, or message us on WhatsApp at +1 (864) 842 1077. We will provide you with a copy promptly upon request.

EXPIRATION OF THIS AUTHORIZATION

This authorization shall remain in effect until the earliest of the following events occurs:

21. The completion of your treatment and discharge from the selected healthcare facility;
22. Receipt by Universal Medical Travel of your written notice of revocation; or
23. A period of two (2) years from the date of signing, whichever comes first.

IMPORTANT NOTICE REGARDING INTERNATIONAL DISCLOSURE

⚠ Important: Once your protected health information is disclosed to a healthcare facility or medical provider located outside of the United States, it may no longer be protected under U.S. HIPAA regulations. International healthcare providers are subject to the privacy and data protection laws of their own country, which may differ from the protections afforded under U.S. law. Universal Medical Travel will take reasonable steps to ensure that all partner facilities handle your information responsibly, however we cannot guarantee that international providers will maintain the same level of privacy protection required under HIPAA.

POTENTIAL FOR RE DISCLOSURE

Please be aware that protected health information disclosed pursuant to this authorization may be subject to re disclosure by the recipient and may no longer be protected by HIPAA once it has been shared with an international healthcare provider. Universal Medical Travel is not responsible for the privacy practices of international facilities beyond the protections established in our Healthcare Facility and Medical Provider Agreement.

PATIENT SIGNATURE AND CONSENT

By signing below, I confirm that:

24. I have read and fully understand this authorization form;
25. I voluntarily authorize Universal Medical Travel to use and disclose my protected health information as described in this form;
26. I understand my right to revoke this authorization at any time in writing and the limitations of that revocation;
27. I understand that signing this authorization is not a condition of receiving treatment and is entirely voluntary;
28. I understand that once my information is disclosed to an international healthcare provider, it may no longer be protected under U.S. HIPAA laws; and
29. I have the right to receive a copy of this signed authorization upon request.