Wittmer Rejuvenation Clinic will be partnering with Elevate MD to continue your managed carefor hormone optimization treatment. Wittmer Rejuvenation Clinic (WRC) is based out of St. Louis, MO,and is licensed to perform services in 45 states and the District of Columbia. WRC Physicians are Advanced BHRT (Bio-Identical Hormone Replacement Therapy) certified through the Worldlink Medical Organization.

The first step in transferring your care to our clinic is to disclose your name and date of acknowledgment off below, in doing so this will allow for our Physicians to obtain your most recent lab results as well as your current prescription protocols. Once completed our staff will coordinate your consultations with our Physicians to establish you as a patient with our clinic and order your prescriptions.

1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Elevate MD is authorized to disclose the following protected health information to Wittmer Rejuvenation Clinic

2. DESCRIPTION OF INFORMATION TO BE DISCLOSED

The health information that may be disclosed is:

Medical records

All treatment records

All past and present information of health care information may be shared

3. PURPOSE OF THE USE OR DISCLOSURE

The purpose of this use or disclosure is Transfer of Care.

4. VALIDITY OF AUTHORIZATION FORM

This Authorization Form is valid beginning on today’s date

5. ACKNOWLEDGMENT

By entering and submitting my name and contact information into the form below, I acknowledge and authorize the release of my medical and treatment records