Authorization to Contact Form

Patient's Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY

THE PATIENT IDENTIFIED ABOVE AUTHORIZES MYERS CHIROPACTIC TO USE AND/ OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLL0WING.
WRITTEN COMMUNICATION
- I give permission to MYERS CHIROPRACTIC to use my address and clinical records to contact me with birthday cards, holiday related cards, newsletters and information about treatment alternatives or other health related information.
ORAL COMUNICATION
- I give permission to MYER CHIROPRACTIC to contact me by phone in the following manner:
Home Telephone
- OK to leave message with detailed information.
- Leave message with call-back number ONLY.
Work Telephone
- OK to leave message with detailed information.
- Leave message with call-back number ONLY.
Consent
By checking this box you are giving MYERS CHIROPRACTIC permission to use and disclose your protected health information in accordance with the directives listed above.
Todays Date
Date Format: MM slash DD slash YYYY

WRITTEN COMMUNICATION