Health Disclosures

Please read the information below and provide your signature in the box below and check that you understand.

I understand that HealthCare QB NC may require health information from my medical records which may include my past and present health conditions, lab values, medications, diet and exercise patterns in order to help me better understand how I am doing.

The information provided to HealthCare QB is strictly confidential and requested solely to allow the proper assessment of the patient's status.

Healthcare QB NC will not use your health information for marketing communications.

I understand that I may receive a copy of this authorization upon request.