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Record Release Form 2019

I authorize any member of the medical staff of West Hartford Chiropractic, LLC and/or any of its employees or representatives to use and/or disclose my protected health information (PHI) as provided below. I understand that I may revoke this Authorization, except to the extent that the entity has already taken action in reliance on this Authorization. The written revocation letter needs to be sent to the Executive Director of West Hartford Chiropractic, LLC. The provision of treatment will not be conditioned on the completion of this Authorization. I understand that once the PHI listed below is used or disclosed as set forth in this Authorization, such information is subject to re-disclosure and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that a fee may be charged for this service and that prepayment may be required.

INFORMATION TO BE USED BY/DISCLOSED FROM: Check the appropriate box(es)
INFORMATION TO BE USED BY/DISCLOSED TO:
PURPOSE OF USE/DISCLOSURE:

INFORMATION TO BE USED/DISCLOSED:

I understand that state law prohibits the use and/or disclosure of the PHI listed below unless specifically authorized by me. I understand that such information will not be used or disclosed unless I indicate by initialing below.

EXPIRATION DATE: Unless I revoke this Authorization or provide a different expiration date below, this Authorization will expire twelve (12) months from the date of execution.

SIGNATURE: If the patient is unable to sign, please indicate the authority of the person who is signing for the patient.

345 N Main Street, Suite 322 ♦ West Hartford, CT 06117

860.232.5556 ♦ [email protected] ♦ [Fax] 860.232.5557

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

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Office Hours

Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Office Hours

Our Regular Schedule

Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed