Personal ROI - Spinal Diagnostics

Authorization to Disclose Personal Health Information

Please complete this form to allow Spinal Diagnostics to share your personal health information with trusted individuals.

1. Voicemail Authorization

May we leave detailed voicemail messages regarding your health information?

Yes, at this phone number: Area Code: - Phone Number:

No, please only leave a message asking me to call back.

2. Authorized Person 1

Full Name: Phone:

What can we disclose to this person?

ANY information LIMITED information Appointment information Other specific information:

3. Authorized Person 2

Full Name: Phone:

What can we disclose to this person?

ANY information LIMITED information Appointment information Other specific information:

4. Acknowledgment

By signing this form, I authorize Spinal Diagnostics to disclose my personal health information to the individuals listed above. I understand that my information may be re-disclosed and may no longer be protected by law.

I also understand that I may revoke this authorization at any time, in writing, except to the extent that action has already been taken based on this permission.

Your Initials (used in all fields):

Signature:

*Your Email (to receive a copy):

Authorization to Disclose Personal Health Information

1. Voicemail Authorization

2. Authorized Person 1

3. Authorized Person 2

4. Acknowledgment

Tualatin

Newberg

Quick Links