I hereby authorize Chameleon Wellness staff to obtain the medical information as indicated from the Facility or Individual listed below.
FACILITY OR INDIVIDUAL:
Check the box next to the type of information that is to be released and/or disclosed:
REVOCATION: This authorization may be revoked in writing by the undersigned at any time prior to the release of information from the disclosing party. Written revocation will not affect any action taken in reliance on this authorization before the written revocation was received.
Requesting Health Professional:
Julie Kenney at Chameleon Wellness
P.O. Box 256
Northborough, MA 01532
508-393-6130
JKenney@ChameleonWellness.com
ALL PATIENT INFORMATION IS PROCESSED ACCORDING TO HIPAA GUIDELINES