PATIENT AUTHORIZATION & CONSENT 4.1 Authorization to Forward Your Information
By submitting this form, I authorize Universal Medical Travel to release, share, and forward my protected health information and medical records — including my medical history, diagnoses, lab results, pathology reports, imaging reports (X-rays, MRI, CT scans, and similar diagnostics), surgical history and operative reports, current and past medication lists and allergy information, photographs submitted for cosmetic or surgical evaluation, and any other health information submitted through this form or provided separately — to the internationally accredited hospitals, clinics, and healthcare providers partnered with Universal Medical Travel to which I have been referred, including the licensed physicians, surgeons, specialists, and administrative and clinical staff involved in coordinating my care, and any other providers or facilities necessary for the evaluation, planning, and delivery of my requested medical procedure, for the purpose of evaluating my condition, developing a treatment plan, providing a procedure quote, and coordinating my medical care.
4.2 Explicit Authorization for Reverse Disclosure of Post-Treatment Records
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 surgical reports, discharge summaries, medication lists, laboratory results obtained during treatment, implant or device information, follow-up care instructions, and any other clinical documentation related to my procedure and recovery. This authorization is directed specifically at the healthcare facility and constitutes my explicit, informed consent for the facility to share these records with Universal Medical Travel for the purposes of professional case management, continuity of care, post-treatment follow-up, and documentation.
4.3 International Data Protection Acknowledgment
I understand that the healthcare facility may be subject to its own national or regional data protection laws, including the Swiss Federal Act on Data Protection (revDSG) or the European General Data Protection Regulation (GDPR). By signing this form, I expressly consent to the facility disclosing my post-treatment medical records to Universal Medical Travel and authorize the facility to rely on this signed form as a valid legal basis for such disclosure. If the facility requires an additional consent form under local law, I agree to sign it prior to my procedure.
4.4 Your Rights
Right to Revoke: You may revoke this authorization at any time by sending a written email to Info@UniversalMedicalTravel.com. Revocation will not affect actions already taken prior to our receipt of your written notice. Right to Refuse: Signing this authorization is entirely voluntary and is not a condition of receiving medical treatment from any healthcare facility. However, without your consent, 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 will therefore be unable to facilitate your medical tourism services. Right to a Copy: You have the right to receive a copy of this signed authorization. Contact us at Info@UniversalMedicalTravel.com or WhatsApp +1 (864) 842-1077. Expiration: This authorization remains in effect until the earliest of: the completion of your treatment and discharge from the selected healthcare facility; our receipt of your written revocation; or two (2) years from the date of signing, whichever occurs first. International Notice: Once your protected health information is disclosed to a healthcare facility or medical provider located outside the United States, it may no longer be protected under U.S. HIPAA regulations. International providers are subject to the privacy and data protection laws of their own country, and your information may be subject to re-disclosure by the recipient. Universal Medical Travel will take reasonable steps to ensure that partner facilities handle your information responsibly; however, we are not responsible for the privacy practices of international facilities beyond the protections established in our Healthcare Facility and Medical Provider Agreement. 