Authorization for Release and Disclose Consent

Patient(s) Name

Date of Birth:

Summers Orthodontist is authorized to release protected health information about the above-named patient(s) in the following manner and to identified persons.

authorize and permit Summers Orthodontics to disclose treatment information on

myself/ patient

to the following member or person(s) below.

Name:

Relationship to patient:

Financial/Account

Orthodontic Treatment

Name:

Relationship to patient:

Financial/Account

Orthodontic Treatment

I DO NOT want information release to anyone other than myself.

Signature:

This authorization is effective

and shall continue to be effective until otherwise revoked in writing by me.

If I choose to revoke this authorization, it will become effective upon receipt but will not apply to disclosures previously made with my consent.

For email and/or text communication I understand that if information is not sent in an encrypted manner there is a risk it

could be accessed inappropriately. I still elect to receive email and/or text communication as selected.

Our office has teamed with Braces Academy to bring you educational videos pertaining to you or your family member's treatment.

Checking this box authorizes members of our team to send you images and short videos regarding treatment

Patient Signature

or Parent/Legal Guardian:

Patient Rights

I have the right to revoke this authorization at anytime.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

Authorization for Release and to Disclose Consent

Entity to Receive Information

Description of information to be released.

Patient Rights