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

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:
If unable to reach me:

Emails


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: