Form

Authorization for Release of Information to Family Members or Caregivers

Only sign this form if you wish to give us permission to discuss your dental information with a family member or caregiver

First Name

Last Name

Date Of Birth

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:

Relationship to Patient

Special Instructions:

Patient Information:

As a patient, you have the right to revoke this authorization at any time and limit what type of information to be disucssed. If revoking consent, we ask that you do that in writing.

Patient/Legal Guardian Signature

Date