Records Release Form

I give my permission for Embrace Family Chiropractic to share the information listed above with the person(s) or organization(s) I have specified in this form

• In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.

• I understand that I do not need to give any further permission for the information detailed above to be shared with the person(s) or organization(s) listed above.

• I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.