(Please fill in the following information if the person responsible is different from self.)
If patient was assisted with this form, enter name of person assisting:
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions.
*Your signature indicates you have received a copy of the HIPAA law and Dental Materials forms and release. Dr. Laith Alsamerai DDS to utilize any dental photographs for lecturing and educational purposes.
At our office, though our focus is on appearance-related dentistry, our team also delivers routine care. With flexible payment plan as well as phasing treatment over time, you and your family can achieve spectacular long-term results. Thank you so much for the opportunity to be of service.
Entity requested to Release Information: Packard Family Dentistry
Purpose of request (who will be authorized to receive information) - I authorize the entity listed above disclose or provide protected health information, about me to the individual listed below.
Secure Communication - Note that regular email is not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not designate email if this is a concern to you.
This authorization will expire at the end of the calendar year, unless you specify an alternate date. You must submit a new authorization form after the calendar year to continue the authorization. Please list the date of expiration if other than the end of the calender year _____________________
You have the right to terminate this authorization at any time by submitting a written request. Termination of this authorization will be effective upon written notice, except where a discussion has already been made based on prior authorization.
We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.