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HIPAA Release

In accordance with HIPAA (Health Insurance Portability and Accountability Act), we protect your medical records and all of your health information. Signing this form allows us to publicly share ONLY your name (if you agreed to allow us to share it) and comments associated with your patient testimonial or survey response. Thank you.

  • This authorization is valid from the date of my/my representative's submission of this form and shall expire at the date you pick below,
  • You may choose how long your authorization is valid by choosing one of the options from the drop down menu above. You may request to retract your authorization at any time.
  • This field is for validation purposes and should be left unchanged.
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