Authorization Form - DS Family and Cosmetic Dentistry

Authorization to Release Protected Health Information
Many of our patients allow family members such as their spouse, significant other, parents or children to call and request information regarding treatment plans, procedures, and financial information. Under the requirements of H.I.P.A.A. we are not allowed to give this information to anyone without the patient’s consent.

If you wish to have your medical information, treatment plan(s) or any financial information released to any family members or outside parties, please specify and sign below.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

I authorize Daniel C. Sluyk, DDS Cosmetic & Family Dentistry (provider) to discuss and/or release my dental records and any information requested to the following individuals:
Name

First NameLast Name
Relationship to Patient:
Name

First NameLast Name
Relationship to Patient:
Name

First NameLast Name
Relationship to Patient:
Name

First NameLast Name
Relationship to Patient:
Patient or Guardian Signature:

Clear
Patient Name (printed):

First NameLast Name
Date

MonthDayYear
Should be Empty: