HIPAA Authorization

Last updated March 1, 2025

By selecting and agreeing to this “HIPAA Authorization”, I hereby authorize Yasha Magyar DO PC (the "Magyar Practice") to use, disclose and otherwise share my Protected Health Information (“PHI”) as described below. 

I understand that this authorization is voluntary.

I understand that if the organization/individuals authorized to receive the information are not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.

Persons/organizations providing information: The Magyar Practice (as defined above) including its owners, employees and agents

Persons/organizations receiving information: Longevix, Inc. (“Longevix”), including its owners, employees, vendors and agents

Type of information: PHI, including, without limitation, laboratory and imaging test orders, results, findings and reports with respect to services rendered at or with respect to the Longevix premises and business

Uses:  To supplement Longevix’ and its vendors’ own programs, products and services at or with respect to Longevix’ business at the Longevix’ premises. For purposes of illustration and without limitation, the DEXA scan, laboratory testing and any medical and related healthcare services rendered by the Magyar Practice at or with respect to the Longevix premises and business are intended to supplement or add value to Longevix’ and its vendors’ own programs, products and services, particularly when combined with Longevix’ own health, fitness, and wellness offerings and program packages. Additionally, for further illustration, the information may enable the creation or maintenance of Longevix customer profiles and more detailed, user-friendly and utilitarian reports concerning the findings of the imaging and laboratory testing and other services.

Expiration of Authorization:

This authorization will expire on the dissolution of the collaborative relationship between Longevix and the Magyar Practice, though customer profiles may continue to be maintained in the ordinary course of Longevix’ business, subject to any separate agreement with or consent required by Longevix.

Revocation of Authorization:

This authorization may be revoked at any time by notifying Longevix and the Magyar Practice in writing by e-mail at legal@longevix.com with a copy to info@networkspine.com, Attn: Yasha Magyar, M.D.  If I revoke this authorization, I understand that it will not have any effect on actions Longevix, the Magyar Practice and other recipients took before it (he, she, they) received the revocation. 

Acknowledgements 

I understand that the healthcare providers listed herein will not receive financial or in-kind compensation (remuneration) in direct exchange for disclosing the health information described above. 

I do understand and acknowledge, however, that the Magyar Practice will benefit financially as a result of its operation at or with respect to the Longevix premises and business, and its and its owner’s and personnel’s association therewith.        

I understand that by signing this authorization form, I authorize the disclosure and use of my protected health information as described above, and that this information may be re-disclosed if the recipient(s) described on this form are not required by law to protect the privacy of the information.

I understand that I may see and copy the personal health information described on this form if I ask for it, and that I get a copy of this form after I sign it, including thereafter upon request.

I understand that signing this authorization is voluntary. I understand that the healthcare providers listed herein will treat me regardless of whether I sign this authorization, but cannot do so at the Longevix premises or in association with the Longevix business (and, as such, offerings, such as, for example, DEXA scans, may not be available at another practice location). 

I understand that my healthcare treatment and my healthcare benefits (and eligibility) for services available outside of the Longevix premises and business will not be affected if I do not sign this form.

I understand that I have the right to revoke this authorization at any time, except to the extent that action has already been taken based upon this authorization.

I represent and warrant that I do not sign this authorization on behalf of a third party, unless I have legal right to sign on their behalf and bind myself and them in their place and stead as qualified personal or legal representative under Federal and State law.