HIPAA Release Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!Let us help you achieve your health goals! BOOK AN APPOINTMENT Leave this field blank Dr. Janine D. Kelly (optional) 1762 Newbridge RoadBellmore, NY 11710 Medical Information Release Form Name Date of Birth Release of Information I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to Spouse Child(ren) Other Information is not to be released to anyone. The release of information will remain in effect until terminated by me in writing. Message Please Call My home My Work My Cell Number If unable to reach me You mey leave a detailed message Please leave a message asking me to return you call Other The best time to reach me is from To Signature Start Drawing Clear Done Start Over Date Witness Signature Start Drawing Clear Done Start Over Date Send
