Patient Name:
Birthdate:
Parent/Guardian: (If patient is under age 18)
E-Signature:
Date:

I hereby authohrize Southern Minnesota Orthodontics, PA, it's employees, agents and associates, to release information as indicated to the parties listed below. I understand that, following information release, Southern Minnesota Orthdontics cannot guarantee protection of the information under the HIPAA privacy regulations. I understand that I can revoke this authorization at any time by proiding written notice to Southern Minnesota Orthodontics.

Authorized Parties

Name of authorized party:
Relationship to patient:
Type of information to be released: Check all that apply
Name of authorized party:
Relationship to patient:
Type of information to be released: Check all that apply
Name of authorized party:
Relationship to patient:
Type of information to be released: Check all that apply