I authorize Kragor Orthodontics LLC to release personal health information ("PHI") for the following purposes:
-Dental services claims information
-Prescription, diagnostic, treatment, and/or care management services
-Reviews required by HHS or HIPAA-compliant health care operations
I authorize that the above information may be released by phone, fax, or mail.
I understand that consent may be revoked by me at any time. I understand why I have been asked to disclose this information and am aware that my patient rights are identified in the practice's Notice of Privacy Practices.