Sellers Orthodontics Adult New Patient Template

Name of Patient

Date of Birth

Sellers Orthodontics is authorized to release protected health information about the above named patient in the following manner and to identified persons.

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Voice Mail

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

Appointment Reminders

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Other person (s) (provide name and phone number) (i.e. parent, Grandparent, Aunt, Uncle, Spouse, Nanny etc)

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

Treatment/ Treatment Plans

Financials

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Email communication-Provide email address*

*For email communication to occur, please accept the disclosure below:

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

Financial

Treatment/ Treatment Plans

Appointment reminders

Breach notification

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Text communication - Provide number *

*For text communication to occur, accept the disclosure below:

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

Appointment reminder

Other

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 inannrooriatelv. I still elect to receive email and/or text communication as selected.

Entity to Receive Information.

Check each person/entity that you approve to receive information.

Photo of patient received by patient or legal guardian

Photo taken by staff (Example: pre/post procedure)

Other

Description of information to be released.

Check each that can be given to person/entity on the left in the same section.

May be posted in office

May be posted on Website

Other

Patient Rights:

I have the right to revoke this authorization at any time.
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.

This authorization will remain in effect until revoked by the patient.

Signature of Patient or Personal Representative

Date

*Description of Personal Representative's Authority (attach necessary documentation)

KEITH T. SELLERS, D.D.S., M.S.

Orthodontic Acquaintance Form

Adult Patient Information

Have we previously treated any family members?

How did you hear about us?

MEDICAL HISTORY

DENTAL HISTORY

ORTHODONTIC INSURANCE INFORMATION

DENTAL INSURANCE INFORMATION ONLY PLEASE

We will be happy to assist you in determining your orthodontic insurance benefits, however all information must be completed and signed.

Sellers Orthodontics

Authorization for Release of Information - Compound Release

Patient Rights: