Authorization For Use and Disclosure of
Protected Health Information

Information to Be Used or Disclosed

Purposes of Disclosure

Persons Authorized to Use or Disclose Information

Information listed above will be used or disclosed by:

Persons to Whom Information May Be Disclosed

Information described above may be disclosed to:
Date of Authorization

Right to Terminate or Revoke Authorization

This authorization may be revoked at any time by submitting a written revocation to MICHAEL W. GOODMAN, MD, P.C., 979 E. Third Street, Suite C-0630, Chattanooga, TN 37403. You should contact the Privacy Officer to terminate this authorization.

Our Location

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403

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Dr. Goodman or Dr. Bagamery.

More Info

If you need additional information, please call us at (423) 267-5677, or send an e-mail to

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