and all healthcare providers furnishing care within Mauricio Chiropractic Center’s facilities to use and disclose my Protected Health Information for the purposes of Treatment, Payment, and Healthcare Operations.
You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and delivered to the address at the bottom of this form. This may be delivered in person or by mail, but it will only be effective when we actually receive it. Your cancellation will not be effective to the extent that we or others will have acted in reliance to this consent.
You have the right to request restrictions on the usage and disclosure of your protected health information for the purposes of Treatment, Payment, or Healthcare Operations. We are not required to grant your request, however, if we do so, the restriction will be obligatory to us.
Mauricio Chiropractic Location * Mauricio Chiropractic Downtown, 205 East Colonial Drive Orlando, FL 32801 Mauricio Chiropractic Dr. Phillips, 7601 Conroy-Windemere Road #204 Orlando, FL 32835 Mauricio Chiropractic Conway, 4747 S. Conway Road Ste A Orlando, FL 32812 Mauricio Chiropractic Winter Park, 1810 Semoran Blvd Ste 104 Winter Park, FL 32792 Mauricio Chiropractic Pine Hills, 1050 Pine Hills Road Orlando, FL 32808 Mauricio Chiropractic E. Colonial, 12278 E. Colonial Dr. Ste 700 Orlando, FL 32826 Mauricio Chiropractic South OBT, 12720 S. Orange Blossom Trail #20 Orlando, FL 32837 Mauricio Chiropractic Poinciana, 860 Towne Center Drive Kissimmee, FL 34759 Mauricio Chiropractic Melbourne, 187 South Wickham Road Unit 101 Melbourne, FL 32904