Chiropractic Clinic Release Authorization Form

Chiropractic Clinic Release Authorization Form

Please read and complete the form below to authorize the release of your chiropractic records to the specified party.

Patient Information

Name

    Date of Birth

      Email

        Phone Number

          Address

            Recipient Information

            Name

              Email

                Phone number

                  Address

                    Authorization Details

                    • I hereby authorize [Your Compapny Name] to release my chiropractic records to the individual or entity listed above.

                    • I understand that this authorization is valid for [specify duration or until further notice].

                    • I understand that I may revoke this authorization at any time by submitting a written request.

                    Patient's Name:

                    Date:

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