Financial Information

Medical and Financial Information Authorization and Release

The purpose of this authorization and release form is to protect your personal information. Pursuant to the Health Insurance Portability and Accountability Act (H.I.P.A.A.; Pub. L. 104 -191, 110 Stat. 1936, 1996) this form is part of your medical record. The legislation is designed to protect the privacy of personal medical records and financial information.

We cannot share any of your personal medical record information except with those persons or entities specifically designated on this form. Please fill out, sign, and present to the Neuroworx staff.