First Name:
Middle Initial:
Last Name:
For More Information or to Report a Problem

You have the right to complain to us and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.

For more information or to file a complaint with us, contact our Privacy Officer by phone or mail as follows: Schlicher Orthodontics
4487 Stoneridge Drive
Pleasanton, CA 94588
(925) 846-3248

To file a complaint with the Secretary of HHS, send your complaint to: Office for Civil Rights
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103

If you have any questions or want more information about this Notice of Privacy Practices, please contact our Privacy Officer.
Acknowledged By (Signature of Patient or Personal Representative):


I, the undersigned, hereby authorize Schlicher Orthodontics to disclose certain protected health information about me to dentists, orthodontists, medical doctors, or photos to be posted on social media sites.
Schlicher Orthodontics is hereby authorized to disclose the following protected health information:

All Medical Records including:
  1. X-Rays
  2. Photos
  3. Treatment Notes
  4. Treatment Letters
The information may be disclosed for the following purpose:
  • To share treatment information with dentists, other orthodontists, medical doctors to ensure a successful treatment for the patient.
  • To post on social media sites (with verbal permission as well).
  • To share information with parents of children over 18 or spouse.
I understand that this request does not apply to: (1) certain health information that is not held in Schlicher Orthodontics’ medical records; (2) psychotherapy notes; (3) information compiled in reasonable anticipation of or for litigation; and (4) other health information not subject to the right of access under HIPAA.

I understand that Schlicher Orthodontics may not condition my treatment on whether I sign this authorization.

I understand that if my protected health information is disclosed to someone who is not required to comply with the federal HIPAA regulations, then such information may be re-disclosed by the recipient and may no longer be protected by HIPAA.

I understand that I may revoke this authorization at any time by delivering a revocation in writing to Schlicher Orthodontics at the address listed above, and if I revoke this authorization, it will have no effect on actions already taken by Schlicher Orthodontics reliance on this authorization.

I authorize the disclosure described herein. I have read and understand this authorization. I am the patient listed on this authorization or am authorized to act on behalf of the patient as the patient’s personal representative.
Signature of Patient or Legal Guardian:
Patient Name:
Printed Name of Patient or Legal Guardian: