Amber Wellness Group, PLLC 1944 NE 45th Ave. Portland, OR 97213 Name(Required) First Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Disclosure(Required) I hereby authorize the following practice/physician to make disclosures of my protected health information as indicated below. I also authorize communication between the person, provider or facility indicated below to provide continuity of care. Name of Person/Provider :(Required) First Phone(Required)Fax Information to be disclosed:(Required) Hospital Records Medical Records Lab Reports Pathology Reports Clinician Chart Notes Physical Therapy Records Emergengy/Urgent Care Records Diagnostic Imaging Reports (X-ray,MRI, CT, Pet, U/S) Other This Information is to be disclosed to:(Required) Dr. Lisa Dickinson, ND Dr. Meghan Bennett, ND Dr. Jade Wienbar, ND Dr. Sumner Van Brunt, ND initialing here(Required) By initialing here, I understand that the information in my health records may include information indicating the presence of a communicable or venereal disease which may include, but is not limited to, hepatitis, syphilis, gonorrhea, HIV and AIDS. The records may also include information about behavioral and/or mental health services and/or treatments for alcohol and/or drug abuse. Consent(Required) I understand the following:(Required)I may revoke this authorization at any time by providing written notice to Amber Wellness Group I may not be able to revoke authorization if our practice has already taken action utilizing the authorization or if it was obtained as a condition of obtaining insurance coverage. Amber Wellness Group will not condition treatment or payment based on my signing this authorization I am signing this authorization freely without pressureThis consent is specifically for the information created from service provided on or before the date of my signatureSignature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA
