Authorization for Release of Information - Compound Release

Please correct the errors described below.

Mark D. Scheiderich, DMD, PA is authorized to release protected health information about the above named patient in the following manner and/or to selected persons.

Check each person/entity approved to receive information.

Check type of information that can be given to person/entity on the left in the same section.

For email communication to occur, please accept the disclosure below
For text communication to occur, accept the disclosure below

Patient Rights

  • I have the right to revoke this authorization at any time
  • I may inspect or copy the protected health information to be disclosed as described in this document.
  • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
  • Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law
  • I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

This authorization will remain in effect until revoked by the patient

Description of Personal Representative's Authority (attach necessary documentation) Revised Oct 2014

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