Release of Healthcare Information

CJS4nBB Release of Healthcare Information

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Release of Healthcare Information

  • (If patient is a minor)
  • Date Format: MM slash DD slash YYYY
  • I request and authorize Body Gears Physical Therapy to release any/all healthcare information of the above-names patient to the following party/parties:
  • This request and authorization applies to healthcare information relating to treatment, condition, scheduling, and billing.
  • Date Format: MM slash DD slash YYYY
  • Enhancing Human Mechanics
    O (877) 709-1090
    F (866) 221-3400
    info@bodygears.com
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