SimonMed Imaging – Peoria Plaza

1. Authority & Accuracy. I certify that I am legally authorized to act for the patient named above and that all statements in this attestation, and the documentation provided, are true, correct, current, and complete. I will promptly notify Expected Health, Inc. dba Expected Healthcare (“Expected Health”) if my authority changes, is revoked, or expires.
2. Valid Authorization/Authority. I affirm that the uploaded authorization or legal authority permits the disclosure of the requested medical records to Expected Health (or to me for the patient’s benefit), and that it has not been revoked, expired, or limited in a way that would prevent this disclosure. I will promptly provide updated or additional documentation upon request.
3. Scope & Minimum Necessary. I am requesting only those records reasonably necessary to fulfill the patient’s request/purpose and understand that the source provider may apply the “minimum necessary” standard as required by law.
4. Sensitive Information. I understand sensitive categories may be included only if permitted by the patient’s authorization or applicable law.
5. If substance use disorder treatment records are disclosed, I understand such records are protected by 42 C.F.R. Part 2. I acknowledge that they may not be re-disclosed by the recipient without the patient’s written consent or as otherwise permitted by Part 2.
6. Redisclosure Notice. I understand that records disclosed pursuant to the patient’s authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA once in the recipient’s possession, except as limited by applicable law (including 42 C.F.R. Part 2, where applicable).
7. Revocation & Expiration. I acknowledge that the patient may revoke their authorization at any time by notifying Expected Health in writing, except to the extent action has already been taken in reliance on it. If the uploaded authorization specifies an expiration date or event, I confirm it has not yet expired or occurred.
8. Electronic Communication & Transfer. I consent on the patient’s behalf (as authorized) to the electronic transmission, receipt, and storage of medical records, which may include unencrypted email or secure portals depending on the source provider’s and Expected Health’s capabilities. I understand Expected Health will maintain reasonable safeguards consistent with applicable privacy and security laws.
9. Conduit Role of Expected Health. I understand and acknowledge that Expected Health acts solely as a conduit/facilitator to request, receive, transmit, and store records at the direction of the patient/authorized representative and is not the provider of care, does not create or alter records, and does not guarantee their accuracy, completeness, timeliness, or clinical interpretation.
10. No Medical, Legal, or Billing Advice. I understand that Expected Health does not provide medical advice, legal advice, or insurance/billing determinations in connection with this request.
11. Cooperation & Audit Trail. I agree to cooperate with reasonable requests from Expected Health or a source provider to verify identity/authority and to supply additional documentation. I agree Expected Health may retain this attestation and uploaded documents as part of its compliance/audit records.
12. Representations & Responsibility. I understand that Expected Health is relying on my representations and the uploaded documentation. If any statement is false, misleading, or incomplete, I accept responsibility for any resulting issues with the request.
13. To the extent permitted by law, I agree to indemnify and hold harmless Expected Health, its officers, employees, and agents solely for losses arising from my misrepresentation of authority or falsified/invalid documentation provided with this request. This clause does not waive any rights the patient has under applicable law and does not expand Expected Health’s obligations beyond those required by law.
14. I declare under penalty of perjury that the foregoing is true and correct.