HIPAA Authorization Release of Information

HIPAA Authorization Release of Information


I authorize the release of information including the diagnosis, examination records, claims information, and billing information. this information may be release.

Information is NOT to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing.


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Contact Us

Office Hours
Monday:8:00 AM - 4:00 PM
Tuesday:8:00 AM - 4:00 PM
Wednesday:8:00 AM - 4:00 PM
Thursday:8:00 AM - 4:00 PM
Friday:8:00 AM - 3:00 PM