Authorization for Release of Information - Compound Release
Patient First Name:
Last Name:
Date of Birth:
Mack Orthodontics is authorized to release protected health information about the above-named patient in the following manner and/or to selected persons.
Check any of the following approved methods to receive information from Mack Orthodontics.
Check type of information that can be given to person/entity on the left
in the same section.
Voice Mail
Financial
Medical
Appointment reminders
Breach notification
Email communication - Provide email address*
* For email communication to occur, please accept the disclosure below:
Financial
Medical
Appointment reminders
Breach notification
Text communication - Provide number*
* For text communication to occur, please accept the disclosure below:
Financial
Medical
Appointment reminders
Breach notification
For
email and/or text communication
I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication as selected.
Photo of patient received by patient or legal guardian
Photo taken by staff (Example: pre/post procedure)
Other
May be posted in office
May be posted on website
Other
Patient Rights:
I have the right to revoke this authorization at any time by contacting our office.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient.
Signature of Patient or Personal Representative:
Date: