Free Chiropractic Clinic Authorization Form Template

Chiropractic Clinic Authorization Form

Please read carefully and complete all sections.

Date

    Name

      Purpose of Authorization

        • Release medical records to another provider.

        • Obtain medical records from another provider.

        • Share information with an insurance company.

        Information to Be Released

          • Complete Medical Records

          • Treatment Plans and Progress Notes

          • Billing and Insurance Information

          • Diagnostic Imaging or Lab Results

          Reason for Sharing Information

            • Continuation of Care

            • Insurance Claim Processing

            • Legal Requirement

            Acknowledgment and Consent

            I understand that I have the right to revoke this authorization at any time by providing written notice to the clinic, except where action has already been taken based on this authorization. I authorize the release, sharing, or obtaining of my medical information as specified above.

            Name:

            Date:

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