Records Request Authorization

The purpose of this authorization is to allow Motion Lord Chiropractic Corporation (“Motion”), its affiliated entities and your other health care providers to effectively coordinate any care you are receiving for injuries or body pain. This will allow our clinical teams to share and request information from providers outside of Motion (imaging, surgeons, specialists and other clinicians), that you are currently seeing or have seen in the past to manage any issue.

  • I hereby authorize Motion and its clinicians to use and/or disclose my protected health information, including all health information pertaining to my medical history, mental or physical condition and treatment received, to a clinician or facility providing treatment to me.
  • I authorize all clinicians and facilities who have provided, or are providing, treatment to me to disclose my protected health information, including all health information pertaining to my medical history, mental or physical condition and treatment received, to Motion.
  • I understand that information disclosed pursuant to this authorization could be redisclosed by the recipient.  Such redisclosure is in some cases not prohibited by California law and may no longer be protected by federal privacy protection regulations.  However, California law prohibits the person receiving my health information from making further disclosure of it unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.
  • I understand that I have a right to revoke this authorization at any time.  My revocation must be in writing and must be sent to:

Motion
ATTN: Privacy Officer
480 2nd St.
Suite 100
San Francisco, CA 94107

 

I am aware that my revocation will not have any effect on any actions taken by the persons I have authorized to use and/or disclose my protected health information before they receive my revocation.

  • This authorization expires upon the earlier of (a) my revocation of the authorization or (b) five (5) years from the date of my execution of this authorization form.
  • I understand that I do not have to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from Motion, nor will it affect my eligibility to obtain payment for such health care.
  • I understand that I have a right to inspect and copy my protected health information (in accordance with the requirements of the federal privacy protection regulations found under 45 C.F.R. §164.524).
  • I understand that I have a right to obtain a copy of this authorization.