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?



2. Authorized Person 1

What can we disclose to this person?

3. Authorized Person 2

What can we disclose to this person?

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.

Signature: