Consent for Release of Personal & Health Information

I authorize the use or disclosure of personal and health (including Medical, Dental, and Pharmacy information) information by Steven M. Hall DMD, PA as described below:

• Any and all personal-end health information Steven M. Hall DMD, PA maintains (including, but not limited to, mental health, HIV, and/or substance abuse records - Cross out any item you do not authorize to be released.)
• Personal and health information regarding the treatment for the following condition or injury:

This information may be disclosed to, and used by, the following individuals or organizations:

I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and send my written revocation to Steven M. Hall, DMD, PA. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to Steven M. Hall DMD, PA when the law provides it with the right to contest a claim under my policy.

I understand that I do not have to sign this authorization and that Steven M. Hall DMD, PA may not condition treatment or payment on whether I sign this authorization.

I understand that once the information is disclosed pursuant to this authorization, it may be redisclosed by the recipient and the information may not be protected by federal privacy regulations.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If signed by legal representative, please provide representative documents as required by state law, i.e. Power of Attorney, Health Care Surrogate, Living Will or Guardianship papers.