Patient Forms New Patient Registration Registro de Nuevo Paciente Authorization for Release of Information Car Accident/Personal Injury Patients Medicare Authorization OBWC Request for Temporary Total Compensation OBWC Notice to Change Physician of Record Authorization for Release of Information Patient Name* First Name Last Name Date of Birth* Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Social Security Number* Patient Address* Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Information Requested From* Address* Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Phone Number* Fax Number Specify Information Requested Purpose or Need for Information I hereby release said Healthcare Provider from any liability or restriction imposed by law upon the disclosure of such information from any professional record of the Healthcare Provider to the person or persons above named, and agree to indemnify said Healthcare Provider for any loss or damage sustained by it by reason of its release of information pursuant hereto. I understand that this authorization applies to all records requested and that it may include treatment for physical/mental/alcohol/drug abuse/Aids. The foregoing authority shall continue to be in force for a period of time not to exceed 60 days (90 days on mental health patients), or until revoked by me in writing, whichever is the lesser period. Signature* [clear] Use your mouse or finger to draw your signature above Signed* Patient Guardian Administrator Executor Next of Kin Date* Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2021 If the patient is not able to sign, state the reason why: Witness Signature [clear] Use your mouse or finger to draw your signature above Date Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2021 Notice to Recipient of Information: This information has been disclosed to you pursuant to the general authorization executed by the person to whom it pertains on his/her legal representative permitting Cleveland Clinic Health System to make such relevant information available to you. Any further disclosure requires the specific written consent of the person to whom it pertains or his/her legal representative; reliance on Cleveland Clinic Health System's authorization for release of relevant information is not sufficient of redisclosure. Sign up with your email address to receive news and updates from Allied Health and Chiropractic. SIGN UP PHONE: 216.685.9975 TEXT: 216-282-4506 FAX: 216.685.9976 Office Hours Monday - Thursday 9am - 6:30pm Friday - Saturday 9am - 1pm Closed Sundays 1810 W 25th Street, Unit 1 Cleveland, OH 44113 RATE OR REVIEW US ON GOOGLE! ©2021 Allied Health and Chiropractic, ALL RIGHTS RESERVED