• Permission to Discuss Protected Health Information

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  • I give permission to Fischman Orthodontics (Dr. Steven A. Fischman and his staff) to discuss the following medical/dental and financial information about me:

  • Fischman Orthodontics (Dr. Fischman and his staff) have my permission to discuss the above information with:

  • I understand that I have the right to revoke my permission at any time except where Fischman Orthodontics has already made disclosures in reliance upon this request. I will notify Fischman Orthodontics in writing if I want to revoke my permission.

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