spierschiropractic.com - HIPAA Release Statement

Medical Information Release Form

(HIPAA Release Form)
Name
Date of birth

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Date
Release of Information:
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:
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This Release of Information will remain in effect until terminated by me in writing.
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Date

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Date
Witness
Date

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Medical Information Release Form