Must be completed for all Authorizations

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or care provider, the release of information my no longer be protected by federal privacy regulations.

* YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*
You may not use this form to release information for treatment or payment except when the information to be released is CHIROPRACTIC NOTES or certain research information.