AUTHORIZATION FOR RELEASE OF PATIENT MEDICAL INFORMATION

I hereby authorize The Dizzy Clinic Llc and the below named individual/practice to release information from my medical record. This information may include all treatment and diagnostic information contained in the record. This authorization allows information to be exchanged between the below named parties and The Dizzy Clinic Llc. If the requested party is one other than the referring physician/provider, a fee may be charged.

I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance upon it. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy regulations.

Physician or Practitioner Name *
Physician or Practitioner Name
ie- Neurologist
Practitioner's Fax Number
Practitioner's Fax Number
Practitioner's Telephone Number
Practitioner's Telephone Number

I hereby release The Dizzy Clinic Llc and the above named persons from all liability and all claims of any nature whatsoever pertaining to disclosure of information regarding medical care and all physical therapy services and follow up care involved in my treatment and from release of the medical records.

Please send any requested information to The Dizzy Clinic Llc.

By completing and submitting the form below, I understand and agree to the above terms.

Name *
Name
Date of Birth *
Date of Birth
Today's Date *
Today's Date