Voicemail Release

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

Voicemail Release

Patient Information

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

AUTHORIZATION TO DISCLOSE PERSONAL HEALTH INFORMATION

I authorize Spinal Diagnostics to disclose my personal health information to the person(s) names on this form. I understand that my personal health information may be re-disclosed by the person(s) and may no longer be protected by law.

I have the right to take back (“revoke”) my authorization at any time, in writing, except to the extent that Spinal Diagnostics has already acted based on my permission.

Please review to ensure the details are correct before completion.

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