HIPAA Form (English – Ortho)

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.

Important note: This page is secured and encrypted using AES_256_CBC, with HMAC-SHA1 (same as the U.S. government) for message authentication and RSA as the key exchange mechanism.

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.
Date of Birth (MM/DD/YYYY)*
Check each entity that you approve to receive information:*
List each person that you approve to receive information:
Family member (s) (Provide Name and Phone #)
Name
Relationship
Phone Number
 
I hereby authorize MyOrthodontist to release the following personal health information to the entities/people listed above:*
List a person(s) that you approve to make treatment decisions:
Name
Relationship
Phone Number
 

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.
Today's Date (mm/dd/yyyy)*

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse To Sign This Acknowledgement*
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices
Today's Date (mm/dd/yyyy)*
This field is for validation purposes and should be left unchanged.

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