Authorization for Release of Information

Name of Patient

Date of Birth

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.

Voice Mail

Choose One

Results of lab tests/x-rays

Other

If other,please indicate

Other person(s) provide name and phone number

Choose one

Financial

Medical

Email communication-Provide email address

Choose an item

Financial

Medical

Appointment reminders

Breach notification

For email communication to occur, please accept the disclosure below

Text communication

Appointment reminder

Provide number

For text communication to occur, accept the disclosure below

Other

For email and / or text communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive email and / or text communication as selected.

Choose an item

Photo of patient received by patient or legal guardian

Photo taken by staff (Example: pre/post procedure)

Choose an item

May be posted in office

May be posted on website

Other

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

Signature of Patient or Personal Representative

Date

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

Your information will be encrypted.

Authorization for Release of Information - Compound Release

Patient Rights

This authorization will remain in effect until revoked by the patient