Prairie Chiropractic, LLC
5 N. Bird St., Sun Prairie, WI 53590
P: 608-318-5959 Fax: 608-318-5958
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
___________________________________________________________________
Name of Patient (Maiden Name if Applicable)
_____________________________________
Date of Birth
___________________________________________________________________
Street Address
________________________________________________
City, State, Zip Code
I authorize the use and/or release of my protected health information (PHI) as described below. I understand that this
authorization is voluntary and is made to confirm my instructions. I also understand that the information used and/or released as
a result of this authorization my no longer be protected by federal privacy laws and my be further used and/or released by persons
or organizations receiving it without obtaining my authorization.
I AUTHORIZE:
TO RELEASE PHI TO:
____________________________________________________
Name of Physician/Health Care Facility
Prairie Chiropractic, LLC
5 N. Bird St.
Sun Prairie, WI 53590
____________________________________________________
Street Address
____________________________________________________
City, State, Zip Code
PHI TO BE RELEASED:
X-RAY(S) AND REPORT(S) of the: Cervical Spine Thoracic Spine Lumbar Spine Pelvis Other________________________
For the following dates:
☐ Within the last year
☐ Within last 2 years
☐ Other_______________________
MRI CD(S) AND REPORT(S) of the: Cervical Spine Thoracic Spine Lumbar Spine Pelvis Other_______________________
For the following dates:
☐ Within the last year
☐ Within last 2 years
☐ Other_______________________
PURPOSE OF DISCLOSURE: Chiropractic Treatment
EXPIRATION DATE: This authorization will expire on _____/_____/_____ (MM/DD/YYYY)
If I do not specify a date, this authorization will remain in effect until this request is processed.
SIGNATURE: I understand that by signing this form, I am confirming my authorization for the health care provider named in
Section 2 above to use and/or disclose the protected health information described above, to the person and/or organization named
in section 3. I understand written notification is necessary to cancel this request.
____________________________________________________________________________
Signature of Patient
_________________________________________
Date
If this authorization is signed by a representative of the patient, please complete the following:
Representative’s Name________________________________________________ Relationship________________________________