Authorization for Release of Chiropractic Medical Records

Patient Information

• Full Name: _________________________ Date of Birth: //____
• Address: ________________________________________________
• Phone: _________________ Email: _________________________

Records To Be Released From

Chiropractic Practice: ________________________________________ Doctor's Name: _____________________________________________ Address: __________________________________________________ Phone: _________________ Fax: _____________________________

Records To Be Released To

Name/Facility: _____________________________________________ Address: __________________________________________________ Phone: _________________ Fax: _____________________________

Information to be Released (Check all that apply)

□ Complete Health Record □ X-Ray/Imaging Reports □ Treatment Plans □ Progress Notes □ Billing Records □ Other: _________________________________________________

Date Range

From: //____ To: //____

Purpose of Release

□ Continuing Care □ Personal Records □ Insurance □ Legal □ Other: _________________________________________________

Authorization

I understand that:

1. This authorization is valid for 90 days from the date of signature
2. I may revoke this authorization in writing at any time
3. Information used or disclosed may be subject to redisclosure
4. Treatment is not conditional upon signing this authorization

Signature: _________________________ Date: //____

For Office Use Only

Request received: //____ Processed by: ________________ Records sent: //____