Release of Information

Complete this before your appointment and your provider can be better prepared during their time with you.

Release of Information

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

AUTHORIZATION TO OBTAIN & DISCLOSE HEALTH INFORMATION

I authorize the use or disclosure of the individual’s health information named below to be used or disclosed as follows:

THE FOLLOWING (*) MUST BE INITIALED BY THE PATIENT TO BE INCLUDED IN THE USE AND/OR DISCLOSURE OF OTHER HEALTH INFORMATION:

DURATION: This authorization shall begin immediately and remain in effect until notified otherwise.

RESTRICTIONS: I understand that the information released may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws or regulations.

RIGHTS: I understand that I may refuse to sign this authorization and that my refusal to sign may not affect my ability to obtain treatment. I may inspect or copy any information to be used and/or disclosed under this authorization in accordance with organizational policy and Spinal Diagnostics has up to 30 days to comply with my written request. I understand that I have the right to revoke this authorization by sending a written statement to the clinic manager of the disclosing location listed above. My revocation will be effective upon receipt, but will not be effective to the extent that this organization has taken action in reliance upon this authorization.

Please review to ensure the details are correct before completion.

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