I grant permission for my healthcare provider and their representatives of Whole Family Chiropractors or RejuvaWell (WFC/RW) to discuss my care, as it becomes relevant, using this disclosure form to share information about my healthcare or discuss financial information for payment on my account with family or friends.
Are there any specific people you would like the staff at WFC/RW to disclose medical/appointment information to?
*WE WILL NOT TALK TO ANYONE THAT IS NOT ON THIS FORM, INCLUDING YOUR SPOUSE, PARENT OR CHILDREN.*
Release my protected health information to the following person(s)/entity: