Susannah Graven LMT
Medford OR 97504
authorize my massage therapist Susannah Graven to disclose my health care information with the following health care providers and/or insurance companies:
I understand that I may refuse to sign this authorization.
I may also revoke this authorization at any time by writing a letter to my massage therapist.
I understand that once my health care information is disclosed, the recipient may redisclose the information and it may no longer be protected by HIPAA or state privacy laws.
I also understand my obtaining care cannot be conditioned on my signing this release.
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