• AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

  • THIS FORM IS OPTIONAL (COMPLETE ONLY IF LOCAL ORTHODONTICS MAY SHARE PATIENT INFORMATION WITH OTHERS SUCH AS STEPPARENTS, GRANDPARENTS, SPOUSE, FRIENDS, ETC.)

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  • I authorize Local Orthodontics to release information, as indicated below, to the following person(s) listed below.

     

  • I authorize Local Orthodontics to contact the individual(s) listed above to convey information as listed above regarding the ‘patient’ in the event that I am unable to be reached by Local Orthodontics.

    I understand that I may revoke/cancel this authorization by notifying Local Orthodontics, in writing, of my intent to revoke authorization, or change the name(s) of those listed to whom the information is to be released.

    Please note that if the patient is under the age of 18, a Legal Guardian must either be present during the Initial Consultation, or must have this page filled out with the name of the individual(s) bringing the patient to the Exam.

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