Authorization for Release of Information – Compound Release
Patient Name:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
Date
DAVIS & GOLDBERG ORTHODONTICS is authorized to release protected health information about the above-named patient in the following manner and/or to selected persons.
Check each person/entity/modality approved to receive information.
Number Authorized to Receive Voicemail Message:
Please enter a valid phone number.
Check type of information that can be given to person/entity via voicemail.
Results of X-rays/diagnostic information.
Other
Other person(s) approved to receive information (provide name and phone number)
01 - Name:
First Name
Last Name
02 - Name:
First Name
Last Name
Check the type of information that can be given to person(s) approved to receive information
Financial
Medical
Email Communication - Provide email address
*For email communication to occur, please accept the disclosure below:
Check type(s) of information that can be given via email
Financial
Medical
Appointment Reminders
Breach Notification
Text communication – Provide number:
*For text communication to occur, accept the disclosure below:
Check type(s) of information that can be given via text
Appointment Reminder
Financial Information
Medical Information
Other
For email and/or text communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected.
I Accept
Photograph Authorization:
*
Photo of Patient Received by Patient or Legal Guardian May be Used
Photo Taken by Staff (Example: Pre/Post Procedure) May be Taken
Other
Photograph(s) of Patient:
*
May be Posted in Office
May be Posted on Website
Other
Patient Rights:
• I have the right to revoke this authorization at any time by contacting our office.• I may inspect or copy the protected health information to be disclosed as described in this document.• Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.• Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer beprotected by federal or state law.• I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient.
Signature of Patient or Personal Representative:
*
Date:
*
-
Month
-
Day
Year
Date
*Description of Personal Representative’s Authority (attach necessary documentation)
Submit
Should be Empty: