HIPAA - Authorization for Release of Medical Information

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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.

Patient’s Name*
Patient’s Name
Date of Birth (MM/DD/YYYY)*
MM
DD
YYYY
Check each entity that you approve to receive information:
- Voicemail and/or text - Phone Number
- Email Address
Phone Number:*
Phone Number:
Email Address:*
Email Address:
List each person that you approve to receive information AND to make treatment decisions:
Family member (s) (Provide Name and Phone #)*
Name Relationship: Phone #
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 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*
Date*
MM
DD
YYYY
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
Signature*
Date*
MM
DD
YYYY
Which office are you going to for your appointment?*

Save and Continue Later

Evelin Hernandez

23:09 30 Aug 18

I've been a patient at Happy Tooth for Some months now and I love everybody there!! Everyone is so kind and very energetic. They do great job with my teeth, I love them! I always enjoy going there and I would definitely recommend this place to people out there who want a there teeth looking good. But i got to say one of favorite staff members is Orlando!! He's really kind and always making jokes and definitely doesn't make it boring.

Jesus4ever 1148

16:29 24 Apr 19

Loved my visit. Dr. Ruth and staff are very friendly.

Elizabeth Martin

18:04 07 Aug 18

Nice friendly people and workers. My daughter has been with them for braces. I would and have recommend people to this place.

Julie Ashburn

14:33 01 Feb 18

Both of my daughters have braces at The Happy Tooth. My oldest daughter went thru her braces ordeal over 6 years ago and honestly I would not have recommended a dog to go there for teeth care. So I was concerned when my youngest required braces as well. My fears were unfounded. New staff.. Very professional and welcoming for the parents and children. The staff before would not allowed parents to go back with their children but now they have no problem with it at all. Kudos for great staff.. Welcoming environment. Thank you for treating us as people and not just cash in your pocket as the previous staff did.

Jayne Goode-Hudson

18:05 09 Mar 17

I'm currently a patient at happy tooth and they have done an amazing job on my teeth and friends and family of mine that have past experience at the happy tooth. I have to say I enjoy being around every employee that works there. They are always so kind to me and give me the best experience when going to my appointments. Janet is always so helpful at the front desk and explains everything so thoroughly to me when I ask questions and so does the doctor and everyone in the back working on me and others teeth. If I had to recommend anyone that needed braces to an orthodontist it would have to be this one. I love The Happy Tooth and wouldn't have traded this experience for anything.

Ambrasia Bullard

17:52 19 Jul 19

This orthodontist is awesome ! They are so helpful and generous. I highly recommended The happy tooth for all your orthodontist needs .

19:25 28 Jul 19

I highly recommend them because they are awesome and so helpful . They are very helpful with questions you may have and very friendly .

Fantashia Johnson

15:12 29 Jul 19

This Orthodonist is the best around, the staff is very friendly and amazing. Orlando is a worker there and he’s one of the best and my favorite.

Kry Production

01:37 27 Jul 19

I was wondering does this place u are able to get braces the same day as your orthodontist consultation

GLO MAR

02:24 03 Aug 19

I can't find the right words to describe the extraordinary work that all the Happy Tooth staff does, they are charismatic, kind, generous, patient, caring, I take my son who has special needs, and they work with him in a phenomenal way , Orlando has a unique patience with my son, welcomes him and attends him very well, my son feels very happy when he goes to his appointments because he knows that he is going to see Orlando who has become his friend.They are very friendly, I highly recommend them, they do an extraordinary job.God bless you.

James Jefferson

20:07 31 Jul 19

Great great people and I love my teeth

Daryl Glover

16:14 14 Aug 19

The happy tooth is a good place too get braces at and I’m happy that I pick too get my brace here

Estella Richardson

17:29 12 Sep 19

It's somewhat far for me since we live on the South end of Fayetteville,but my son procedure was done in a timely manner and the staff is very friendly Smiles all over the place and very patient with children. That may be fearful of the procedure of getting braces.

Zaniyah Jefferson

21:47 25 Sep 19

I am a patient here and I really love it! I’m very happy because they gave me braces and my teeth have straightened so much!

Raul Pena

05:43 10 Jan 20

Appointments go very quickly, I don't have to wait long to start, and the staff make things go smooth and easy. The team here are very kind, and are willing to explain whats happening and what the plan is every step of the way. Great place, very happy with their service.

Juan Castillo

22:54 10 Jan 20

Alisha was great! She is very good and sweet with her patients. Dr. Ruth is very nice as well. The front desk was very efficient and professional. :)

DeAnna Sampson

14:39 09 Jan 20

Great place fun staff in and out in 30 minutes Dr.Murray is very nice and Amanda she’s really nice I love it been going for 2 years now ????❤️

Uriel Venegas

21:33 08 Jan 20

I’ve been going to the happy tooth for a year and my teeth have been improving and so far they have been getting Getting straighter I thank Orlando for helping me with my teeth ????

Yari Gabriel

00:21 21 Jan 20

Today I had an appointment with these guys and it went awesome like always! All of the staff are great at what they do????. Today the one that did my braces was Alisha, she’s a really cool person she worry’s about how you’re doing and always asks if anything hurts or bothers. I’ve only seen her twice and both of these times my braces have been done excellent!!

Samantha VanTeslaar

14:11 23 Jan 20

Amazing. Been attending for over a year. Very sweet as well. I love Orlando and Alicia, they’re the best.

SULY LUNA

01:15 28 Feb 20

It was a great experience! Janet the treatment coordinator was amazing and very sweet! Everyone at the office was really nice, I definitely recommend this orthodontist.

Nekiasta Hunt

16:27 10 Mar 20

Today I got my braces off, they are beautiful and retainers fit perfectly. This orthodontist had very helpful people who loved to make people laugh. They were so awesome and I had a great experience.

Lisa Morris

20:30 28 May 20

They are very compassionate and get you in and out in timely fashion. Very informative and professional

Crystal Goins

18:10 28 Sep 20

It's Always a Pleasant, Happy surrounding and the ppl. Are Very Nice and they do a Wonderful Job and are very Quick, fast acting to get you in and out with your full service visit. and you are in at appropriate time in the back in the chair ready to go. Everyone works Good together as a team and they staff and Orthodontist keep the Parents up to date on things very clear and it's a good place to go to. We Love it there with them and where they are located. It's Awesome and they get they do such great work. They think about thepatients and parents first.

courtney hogans

20:46 20 Nov 20

The staff is so wonderful since we met 4 years ago starting my three children with braces. They have been there no matter what and I appreciate them to the fullest. My children and I appreciate all the extra miles you have takem to ensure their dental care is addressed.Kim, Iris Dr, staff working to adjust their teeth, front office♥LoveCourtney , Tyler, Yasmin, Brielle

Heather Crawford

18:30 19 Oct 20

Even though I haven't started the process with Happy tooth yet I have already had such great customer service from Heather the office manager. She has keptme updated awaiting one of my daughters approvals and has went above and beyond! Since I have spoken to the office manager I am full confident that I will have my approval and I will be satisfied with the Happy tooth for my daughters treatment! Thank you so much for all your hard work Heather !!

Dewie Ward

21:42 14 Oct 20

Happy Tooth and the staff that work there has been absolutely great. My daughter, Seymora Netherly, has been going there since December 2019. I have had some problems with my vehicle and being out of work therefore that has put me a couple months behind on my payments, and Mrs. Heather and the rest of the staff has worked with me really well about my payments and I am very grateful and appreciative. Happy Tooth Stanford is a great place to carry your children if they need the help that you are looking for. The staff are nice and caring and they care about each and everyone of their patients. I could not have chosen a better place to took my daughter. Thank you Happy Tooth. Sincerely, Ms. Ward

HEATHER HOWARD

17:05 13 Aug 20

My son goes to this happy tooth 🦷 in Sanford! We love it! They make sure that we are pleased with every visit we have had! Also both my sisters went to this location! My son broke his braces and they seen us that next day. We didn’t have to wait or Nuttin! Best please in town to get braces!

HIPAA Form (English – Ortho)

Authorization for Release of Medical Information

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

MyOrthodontist

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Authorization for Release of Medical Information

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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