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Motocross Authorization for Release of Medical Records
Permission to Text

Emergency Contact Information

Social Media Handles

Please like/follow @mcginleyclinic on all handles.

Authorization for Release of Protected Health Information (PHI) to Personal Representatives

Personal Representatives such as primary care doctor, parent, trainer, coach, manager, or legal guardian.

I, the undersigned, authorize The McGinley Clinic to release my PHI to the personal representatives listed above.

Types of Information to be released:

I understand:

  • The above-listed person(s) authorized to receive the requested information are not covered entities governed by federal privacy regulations. Therefore, the PHI being disclosed will no longer be protected by federal privacy regulations.

  • I may inspect or copy the PHI to be used or disclosed under this authorization.

  • The McGinley Clinic has a comprehensive Notice of Privacy Practices available that describes uses in detail. I am free to refer to this notice at any time.

  • I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, payment, or eligibility for benefits.

  • I may revoke this authorization in writing at any time by notifying the office. My revocation will not apply to actions taken prior to the date the office receives my written request to revoke authorization.

Media Release:

I grant full permission for my name, image, likeness, and recorded media to be used for marketing and promotional purposes across all platforms of The McGinley Clinic.

By signing below, you confirm that the information provided is accurate and complete.

Thank you!

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