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I expressly agree and it is my understanding that I am allowing Pure Family Chiropractic to release my medical records to a designated recipient of my choosing. The information to be released is intended to provide a copy of my complete medical records from Pure Family Chiropractic to a recipient I specify. I understand it is my responsibility to accurately and to the best of my knowledge provide Pure Family Chiropractic with the information necessary to deliver my records to the correct recipient.
It is my understanding that the information to be released will be used for one or more of the following purposes: At the request of the individual | Additional Medical Care | Change of Provider | Legal Investigation/Action | Other (please specify below)
I have had an opportunity to review and understand the content of this authorization form. By signing this authorization form, I am confirming that it accurately reflects my wishes.