Brett Crell DDS P.C.

Medical Information Release Form

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
PLEASE COMPLETE ALL SECTIONS OF FORM AND SIGN.
Patient First Name:
Patient Last Name:
Patient Birthdate:
Release Authorization:

Voicemail and/or Text Messages
Messages may be left by employees of Brett Crell DDS P.C. or an Automated Messaging Service


Emails

Pictures
Social Media

Authorization:
I certify that I have the legal authority under applicable law to act on behalf of the patient identified above.
Personal Representative E-Signature:
Relationship to Patient:
Date: