Consent for Release of Medical Information

CONSENT FOR RELEASE OF MEDICAL INFORMATION

RELEASE COPIES OF MY MEDICAL RECORDS TO:

iCare Chiropractic, P.A.

5226 West Flagler Street, Miami FL 33134

Phone: 786-391-3868 Fax: 786-391-4189

For the purposes of medical treatment, which shall include: entire record (including and excluding sensitive PHI), medication list, problem list, list of allergies, immunization records, most recent history & physical, laboratory results, x-ray and imaging reports, consultation reports, visits/encounters, other.

The facility named above is released from all legal liability that may arise from the release of the information requested and is in compliance with HIPAA Privacy and Security Rules. This authorization is subject to revocation at any time, by written request, except to the extent that action has been taken into reliance thereon, and in any event this authorization expires without express revocation 90 days from the date that appears below.

Thank you for taking the time to fill out this form.

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Our Location

5226 West Flagler St. | Miami, FL 33134

Office Hours

Our General Schedule

Monday:

9:00 am-1:00 pm

3:00 pm-7:00 pm

Tuesday:

2:00 pm-7:00 pm

Wednesday:

9:00 am-1:00 pm

3:00 pm-7:00 pm

Thursday:

2:00 pm-7:00 pm

Friday:

9:00 am-1:00 pm

3:00 pm-7:00 pm

Saturday:

Closed

Sunday:

Closed

Contact Us Today!

We look forward to hearing from you.