HIPAA Authorization Form

This form designates Solidarity HealthShare("Solidarity"), Advanced Medical Pricing Solutions ("AMPS"), and D. Douglas Aldeen, Esq. as your Designated Personal Representatives to act on your behalf in communicating and handling billing and payment matters with your healthcare providers. This form does NOT authorize Solidarity, AMPS, or D. Douglas Aldeen, Esq. to act on your behalf for your treatment or care. In addition, Solidarity and AMPS are not insurance companies and do not guarantee payment of medical costs.
Note to providers: By accepting this form, you acknowledge that Solidarity, AMPS, and D. Douglas Aldeen,Esq. are the undersigned Patient's Designated Personal Representatives for correspondence regarding payment and billing of the Patient or his or her dependent(s). As such, it is expected that you will cooperate with Solidarity, AMPS, and D. Douglas Aldeen, Esq. for purposes of enabling the Patient, who is self-pay, to pay his or her medical bills.
I, Full Name*, direct my health care and medical services providers to disclose (in the form of verbal, electronic record or access through an on line portal, or hard copy),and release my Protected Health Information (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing for all conditions) for payment and billing purposes to my Designated Personal Representatives as listed herein. Any future correspondence or communication should be directed to: