Many of our patients wish to allow family members such as a spouse or parent to call and request dental or billing information. In accordance with HIPAA guidelines, we respect our patient's privacy and require consent before discussing such information with others. If you wish to have your dental (including any planned treatments or diagnosis) and billing information released to family members we reqwuire the signature of this release form. Signing the form below will allow us to discuss your dental information only with those people you list below.
I authorize Temple Family Dentistry to release/discuss my dental and/or billing information to (or with) the following individuals: