I hereby authorize Helix Care Chiropractic and Wellness, PLLC, including its licensed providers and staff, to disclose relevant and limited protected health information (PHI) related to my current condition or injury, including diagnosis, functional limitations, treatment recommendations, and activity restrictions, to designated staff of Box Roket and its affiliated entities (the umbrella organization for the CrossFit gyms).

This disclosure is for the purposes of coordinated care, rehabilitation support, strength and conditioning guidance, and injury prevention.

I understand that this authorization is voluntary and that I may revoke it in writing at any time, except to the extent that action has already been taken in reliance upon it.