Medical Information Release Form

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

This form must be completed by the patient’s Parent or Legal Guardian. Please provide current court ordered guardianship papers stating the person who has been appointed guardian (if other than the parent).

* Patient First Name:

Middle Initial:

* Last Name:

* Birthdate:

Release of Information

I authorize the release of limited information i.e. review of appointment and instructions given, oral hygiene counseling, scheduling of future appointments to anyone accompanying the patient to his/her appointments

I authorize the release of complete information including the diagnosis, records, billing, and examination rendered to me and claims information. This information may be released to:

Spouse (Name below)

Child(ren) (Name(s) below)

Other (Specify below)

Information is not to be released to anyone.

Name of Person Completing Medical Release:

Relationship to Patient:

Messages

Messages may be left by employees of GKG Orthodontics or an Automated Messaging Service

Please Call:

Cell Number

Home Number

Other Number

If unable to reach me:

You may leave a detailed message.

You may text a detailed message.

Please leave a message asking me to return your call.

Other (Specify below)

Emails

I authorize GKG Orthodontics to email me pictures of the patient(s) and x-rays, appointment reminders, school excuses, and statements and receipts.

Authorization

This Release of Information will remain in effect until terminated by me in writing.

Patient (or Guardian if under the age of 18) E- Signature:

If under the age of 18: Parent/Guardian Name:

Date: