HIPAA RELEASE OF INFORMATION

Patient Name:*

First NameLast Name

DOB:*

Date

Our practice is dedicated to maintaining the privacy of patient identifiable health information (also called protected health information, or PHI). By federal and state law, we must follow the terms of the HIPAA Notice of Privacy Practices. In accordance with the HIPAA Notice of Privacy Practices, WingHaven® Orthodontics requires written permission to discuss patient information with any individual other than the Parent/Legal Guardian or Adult Patient (over 18 years old) who has signed the HIPAA Notice of Privacy Practices form.

By signing this form, I authorize Cheryl L. Held, D.D.S., M.S., P.C. and the Team of WingHaven® Orthodontics to use and disclose certain protected health information (PHI) about blanks* to the following individuals:

Relationship to Patient:*

Name:*

First NameLast Name

Phone:*

Please enter a valid phone number.

*

Full Disclosure of All Patient InformationTreatmentFinances to Include: Contract Account Balance, Payment History, and Insurance Benefits

Relationship to Patient:

Name:

First NameLast Name

Phone:

Please enter a valid phone number.

Full Disclosure of All Patient InformationTreatmentFinances to Include: Contract Account Balance, Payment History, and Insurance Benefits

Relationship to Patient:

Name:

First NameLast Name

Phone:

Please enter a valid phone number.

Full Disclosure of All Patient InformationTreatmentFinances to Include: Contract Account Balance, Payment History, and Insurance Benefits

*

(All Patients) By checking this box, I also agree to the transfer of these records to other medical and/or dental professionals for treatment purposes, as deemed necessary by Cheryl L. Held, D.D.S., M.S., P.C.(Transfer Cases) By checking this box, since we are transferring to Dr. Cheryl L. Held’s WingHaven® Orthodonticsfor orthodontic care, I also agree to the release of any prior orthodontic records by my prior orthodontist.

Name*

First NameLast Name

Signature*

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Date*

Date