Authorization for Release of Information

Authorization for Release of Information

Compound Release
Patient Name

First NameLast Name
D.O.B.

MonthDayYear
Date
Mahaffey Linkous Orthodontics is authorized to release protected health information about the above-named patient in the following manner and/or to selected persons.
Check each person/means of communication approved to receive information.

Voice MailOther Person(s) (Provide Name & Phone Number)Email Communication (Provide Email Address*)Text Communication (Provide Number*)
Name + Phone Number and/or Email Address of Person Approved to Receive Communication
Check the type of information that can be given to person/entity named above.

Results of Lab Tests/X-RaysOther
Check the type of information that can be given to person/entity named above.

FinancialTreatment Plan
Check the type of information that can be given to person/entity named above.

FinancialTreatment PlanAppointment Reminders
Check the type of information that can be given to person/entity named above.

Appointment RemindersOther
For email and/or text communication, I understand that if information is NOT sent in an encrypted manner, there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected.
Permission to Release Video & PhotographsDecline to Release Video & Photographs
Video & Photographs May Be Posted on Social MediaVideos & Photographs May Be Posted In Office
Patient Rights:
- I have the right to revoke this authorization at any time by contacting our office.
- I may inspect or copy the protected health information to be disclosed as described in this document.
- Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
- Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
- I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient.
Signature of Patient or Personal Representative

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