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: