This information may be disclosed to and used by the following organization:
Kyle J. Pankonin, D.C.
Red Rock Chiropractic Center
202 Main Street, PO Box 517
Lamberton, MN 56152
The reason for disclosure of this information is for the following reason:
1. Continued Health Care
I understand I have a right to revoke this authorization at any time yby presenting a written revocation to the medical record department. I understand the revocation will not apply to:
1. Information already released in response to this authorization
2. My insurance company when the law provides my insurer with the right to contests a claim under my policy.
I understand authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition: