Release of Records

                                                                                                                                                                         

                                                                                         Let us get started filling out this form.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

INFORMATION TO BE RELEASED FROM:

INFORMATION TO BE RELEASED TO:

TYPE OF INFORMATION TO BE RELEASED

ACKNOWLEDGEMENT

I understand information on my record may include sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or related diseased, or may include information about behavioral or mental health services or treatment for alcohol and/or drug use. 

 

I understand that any disclosure of information carries with it the potential for disclosure by the recipient and that the information then may not be protected by federal confidentiality rules. 

 

I understand that I have the right to revoke this authorization at any times. I understand that my revocation must be in writing. I understand that the revocation will apply to information released prior to revocation. 

 

I understand authorizing disclosure of this health information is voluntary. I understand that I am not required to sign this authorization to receive treatment. I understand that if this information is required for participation in a research study, my enrollment may be denied if I do not sign this authorization. 

 

I understand that I may inspect or request a personal copy of the information to be disclosed. 

PATIENT AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I hereby authorize the release of the above specified medical information contained in my medical record. 

Please Note: Authorization valid for 180 days only and may be revoked in writing at any time prior to 180 days by notifying our office. 

 

WE CANNOT PROCESS YOUR REQUEST WITHOUT COMPELTE INFORMATION. 

Thank you for taking the time to fill out this form.


Our Location

2215 Jordan Ave. The condos behind McDonalds and Jordan Creek Mall. We are the 3rd building on the right, on the one-way street.

Office Hours

Massage times may differ from Front Office times

Open

Monday:

8:30 am-12:00 pm

2:00 pm-5:00 pm

Tuesday:

8:30 am-12:00 pm

Wednesday:

8:30 am-12:00 pm

2:00 pm-5:00 pm

Thursday:

8:30 am-12:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed