Release of Medical / Dental Information

Release of Medical / Dental Information

Authorize the release of your medical or dental information by completing the form below.
Patient First Name
Patient Last Name
Patient Birthdate
Parent/Guardian Name
Patient/Guardian Email
Name 1
Phone 1
Relationship 1
Name 2
Phone 2
Relationship 2
Name 3
Phone 3
Relationship 3
Name 4
Phone 4
Relationship 4
I, the undersigned, as the patient or his/her authorized representative (decreed by law), do hereby authorize Lazin Orthodontics, to release to the noted insurance company(ies) or other appropriate agency(ies) that information which is necessary to validate this insurance claim.

I hereby give permission to disclose (discuss, and speak with) personal medical/dental information about my or my child's treatment to the individuals listed below. Unless specifically listed below, Lazin Orthodontics may not speak to any individual concerning the medical or financial information of this patient - including appointments, test results, prescriptions, school or work excuses, etc. This includes your spouse, children, children's step-parent, & insurance subscriber. WE MUST HAVE THEM LISTED BY NAME AND A SIGNATURE OF THE CUSTODIAL PARENT.
Signature
Please Type Signer's Name
Should be Empty: