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.

Patient First Name*

Patient Last Name*

Date of Birth (MM/DD/YYYY)*

Check each entity that you approve to receive information:*

Voicemail and/or text - Phone Number

Email Address

Phone Number*

Email Address*

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:*

Information about my invoice or accounts payable

Information about dental appointments

Prescription, diagnostic, treatment, and/or care management services

I DO NOT consent to share my personal health information

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.

Signature of Patient or Legal Guardian*

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

First Name*

Last Name*

Signature*

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

Which office are you going to for your appointment?*

Name

This field is for validation purposes and should be left unchanged.

HIPAA Form (English – Ortho)

Authorization for Release of Medical Information

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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