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: I authorize the release of information including the diagnosis, records, billing, examination rendered to me and claims information.
Information is NOT to be released to anyone.

Please LIST NAMES & RELATIONSHIP TO PATIENT that information may be released to:

* Name:

* Relationship to Patient:

Name:

Relationship to Patient:

Name:

Relationship to Patient:

Name:

Relationship to Patient:

Voicemail and/or Text Messages

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

I authorize Troy Orthodontics, PC or an automated messaging service to leave a voice or text message on my home, cell or work phone number for myself or the patient.
I DO NOT authorize Troy Orthodontics, PC or an automated messaging service to leave a voice or text message on my home, cell or work phone number for myself or the patient.

Emails I authorize Troy Orthodontics, PC to email appointment reminders, school excuses, statements and receipts.
I DO NOT authorize Troy Orthodontics, PC to email appointment reminders, school excuses, statements and receipts.

Pictures I authorize Troy Orthodontics, PC to place pictures of the patient(s) in the office.
I DO NOT authorize Troy Orthodontics, PC to place pictures of the patient(s) in the office

Social Media I authorize Troy Orthodontics, PC to place pictures of the patient(s) on office related social media.
I DO NOT authorize Troy Orthodontics, PC to place pictures of the patient(s) on office related 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: