AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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.)
Name *

First Name Patient Last Name
Patient's Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize Local Orthodontics to release information, as indicated below, to the following person(s) listed below.
Name *

First Name Last Name Relationship
Check the information to Release: *

Any Clinical Financial
Name

First Name Last Name Relationship
Check the information to Release:

Any Clinical Financial
Name

First Name Last Name Relationship
Check the information to Release:

Any Clinical Financial
Name

First Name Last Name Relationship
Check the information to Release:

Any Clinical Financial
Name

First Name Last Name Relationship
Check the information to Release:

Any Clinical Financial
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.
Signature of Patient or Parent/Legal Guardian if Patient is under 18 years of age

Clear
If Parent or Guardian, Full Name

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

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.)