Medical Records Request

HIPAA AUTHORIZATION TO RELEASE CHIRO ONE RECORDS

Clinic Location(s) Authorized to Make the Requested Disclosure:

Full Patient Legal Name:

Date of Birth:

Phone:

Address:

Unit/Apartment/Suite #:

City:

State:

Zip Code:

You authorize the release of your medical information specified below from the above listed Chiro One Wellness Center Clinic Location (“Chiro One”) to:

Name of Person or Entity to whom Chiro One May Make the Requested Disclosure:

Phone:

Address:

Unit/Apartment/Suite #:

City:

State:

Zip Code:

Purpose for Disclosure:

Other:

Records Date Range: From:

To:

RECORDS TO BE RELEASED

(There may be fees for obtaining copies of medical records.) Please select or list specific documents to be requested (check all that apply):

Patient Intake Paperwork

Patient Signed Consents

X-Ray Films*

Physician Notes

Correspondence

Other: (Please List)

Examinations/Consultations

Treatment Plans/Prescriptions/Treatment Recommendations

Reports

Bills/Invoices/Payments

Financial Commitments

* Hard films are to be returned back to the office within 30 days.

Method of Delivery

(Select One Only)

U.S Mail

Email*

Fax*

Other

*Records Disclosed by Email or Fax:

You understand that it is Chiro One’s policy to send records by U.S. Mail. Despite that, you have verified that the recipient’s email or fax is secure and that the recipient is the only person or entity that is authorized to access the email or fax. You hereby release Chiro One from any claims that this email or fax may not be private to the recipient, and you specifically request Chiro One to email or fax the above requested records to the following email address or fax number:

Fax:

Patient Initials:

You understand that:

The information in my record may contain information regarding sexually transmitted diseases or HIV/AIDS. Your record may also contain information about mental health services or treatment for alcohol and/or drug abuse.
You are not required to enter into this Authorization, and Chiro One may not condition treatment, payment for treatment, enrollment or eligibility for benefits on whether you sign this Authorization. Chiro One is allowed by law to disclose information regarding treatment, payment, or health care operations without my consent.
This Authorization will expire one year from the date of signature below. You may revoke this Authorization at any time in writing to Chiro One, except to the extent Chiro One has already relied on your authorization and has not had a reasonable opportunity to act when it receives the revocation.
Federal privacy regulations will no longer apply to the information disclosed, and the information disclosed to the recipient may be re-disclosed to others.
A copy of this Authorization is as valid as the original Authorization.
You are entitled to a copy of this Authorization.
I certify that I am the patient requesting my own records or that I have legal authority to request the records on behalf of the patient by virtue of my relationship to the patient entered above. I agree to be responsible for any claims and damages asserted by or on behalf of the patient against Chiro One with respect to any misrepresentation of my authority to request the records from Chiro One.

Relationship to Patient:

Email:

Signature:
Use mouse or finger to sign

Clear

Printed Name:

© 2024 - TVG-Medulla, LLC | Phone: 630-468-1824 | Email: medicalrecords@chiroone.net