HIPAA Authorization or Disclosure and Acknowledgement - MyOrtho

Authorization for Release of Medical Information

This form must be completed by the individual whose protected health information is to be disclosed or by a parent or guardian if the person is a minor under state law.

Patient's First Name:*

Patient's Last Name:*

Patient's Date of Birth*

Office Location:*

Check entities approved to receive information:*

I approve to receive information (voicemail and/or text) to the provided phone number I approve to receive information to the provided email address.

Phone Number:*

Email*

List 2 family members or friends that you approve to receive information:

Name:

Relationship to patient:

Phone:

I hereby authorize MyOrthodontist to release the following personal health information to the entities/people listed above:

Authorized to access treatment records (including appointments and financial information) This person can make treatment decisions.

Name

Relationship to patient

Phone

I hereby authorize MyOrthodontist to release the following personal health information to the entities/people listed above:

Authorized to access treatment records (including appointments and financial information) This person can make treatment decisions.

I understand that this 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.*

Agree

Patient or Legal Guardian Signature*

[clear]

Use your mouse or finger to draw your signature above

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse To Sign This Acknowledgement*

I have received a copy of this office’s Notice of Privacy Practices

Date

clientID