Zirbel Orthodontics Authorization for Disclosure of Health Information

Zirbel Orthodontics Authorization for Disclosure of Health Information

This form is used to authorize Zirbel Orthodontics to release protected health information to another person or entity.
The individual whose information may be disclosed:
Patient's Full Name:*

First NameMiddle NameLast Name
Patient's Birthdate:*

MonthDayYear
Date
The information authorized to be disclosed is for the following periods:
From*

MonthDayYear
Date
To*

MonthDayYear
Date
INFORMATION TO BE DISCLOSED: All information related to the active orthodontic treatment, retention phase, billing and appointments.

This information is to be disclosed to:
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that I may revoke this authorization at any time by giving written notice of my revocation to Zirbel Orthodontics. I understand that authorizing the disclosure of this information is voluntary, and that I can refuse to sign this authorization.
I am an authorized representative for:*
Relationship to the Patient:*
Signature of Authorized Representative:*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: