Permission to Verbally Discuss Protected Health Information (PHI)
Name
First Name
Last Name
I give permission to Ridgefield Dental Arts to discuss the following health information about me (check all boxes that apply):
Scheduling/Appointment information
Dental information, including my symptoms, diagnosis, medications, and treatment plan
Billing and payment information
With the following named person/persons:
Relation to Patient
Please Select
Spouse
Parent
Family member
Friend
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Relation to Patient
Please Select
Spouse
Parent
Family member
Friend
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Relation to Patient
Please Select
Spouse
Parent
Family member
Friend
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
Submit
Should be Empty: