Consent for Request of Medical Information

CONSENT FOR REQUEST OF MEDICAL INFORMATION

I HEREBY AUTHORIZE AND REQUEST THAT ICARE CHIROPRACTIC, P.A. REQUEST COPIES OF MY MEDICAL RECORDS FROM MY PREVIOUS HEALTH PROVIDER(S):

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

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We look forward to hearing from you.