Consent of Disclosure Form

Consent of Disclosure

  • 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 others or we have acted in reliance upon 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. Our Posted Privacy Policy provides more detailed information about the usage and disclosure of your Protected Health Information. You have the right to review our Posted Privacy Policy before you sign this consent. We reserve the right to amend the terms of our Posted Privacy Policy. You may obtain a copy of the current policy from our front desk.

  • If you are signing as the patient’s representative:

  • This field is for validation purposes and should be left unchanged.