Form

Authorization to Release and Discuss Dental Information

Under HIPAA privacy regulations, our office is permitted to communicate only with patients directly, their legal guardians, insurance providers, and treating physicians—unless we have written authorization from the patient to discuss information with others.

The following Authorization to Release Information form must be completed and signed by all adult patients aged 18 years and older.

Patient First Name

Patient Last Name

Patient Date Of Birth

Please provide the full names of any individual(s) you wish to authorize below. If you do not wish to grant permission for the release of your information to anyone other than those listed above, please select the “Do NOT Release Information” option.

I hereby authorize the following person(s) to communicate with the office of Manlius Dental Group on my behalf regarding the items listed below:

Name of Authorized Person:

Relationship to Patient:

Phone Number

Please check all that apply:

Name of Authorized Person:

Relationship to Patient:

Phone Number

Please check all that apply:

I understand that my explicit consent is required to release any healthcare information. By signing below, I acknowledge that this information will be stored in my medical record, and the permissions outlined above will remain in effect until I revoke them in writing. It is my responsibility to inform my healthcare provider(s) if I wish to update or change any of the contacts listed above.

Signature of Patient

Date