To release my dental records to:
Melville Medicine
1545 East Southlake Blvd, Suite 110 Southlake, TX 76092
Phone: 817-676-2010 Fax: 817-549-4687
Please send the following information:
I understand that my records may contain information regarding the diagnosis or treatment of HIV (AIDS virus) and other sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.
and staff from all legal responsibility that may arise from the act hereby authorized.
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.
To be valid, this authorization must be dated within 90 days of the request for the information and can be revoked at any time, providing that the information has not yet been released. No information for medical treatment received after the date of this authorization will be released.
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
I wish to be contacted in the following manner.
(Please check in each section)
I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document if requested.
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.
To release my medical records to:
Melville Medicine
1545 East Southlake Blvd, Suite 110 Southlake, TX 76092
Phone: 817-676-2010 Fax: 817-549-4687
Please send the following information:
I understand that my records may contain information regarding the diagnosis or treatment of HIV (AIDS virus) and other sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.
and staff from all legal responsibility that may arise from the act hereby authorized.
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.
To be valid, this authorization must be dated within 90 days of the request for the information and can be revoked at any time, providing that the information has not yet been released. No information for medical treatment received after the date of this authorization will be release.
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.
Your answers will give us a better understanding of your medical concerns and conditions. If you are uncomfortable with any questions, feel free not to answer them. Best estimates are fine; however, be specific whenever you can. Please contact family members if you need assistance completing the family history section. If you need more space, simply attach as many additional pages as you need. Thank you!
Medications: Please list all prescription and non-prescription medications, vitamins, home remedies, and herbs.
When was your most recent:
Cigarettes:
How many daily servings of the following do you have:
How many times a week do you consume the following items?
Please check any current problems you have on the list below.
Please indicate the current status of your immediate family members. Include if each person is alive or deceased; the person’ age now and or at the time of death; if applicable, the cause of death; and any other relevant comments.
We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this office, whether made by your personal medical provider or others working this office. This notice will inform you about the ways we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.
Make sure that health information that identifies you is kept private.
Give you this notice of our legal duties and privacy practices with respect to health information. Follow the terms of the Notice of Privacy Practices that is currently in effect.
For treatment, for payment, for health care operations, for appointment reminders, as required by law, public health risks, health oversight activities, lawsuits and disputes, law enforcement, coroners, health examiners and funeral directors, to avert a serious threat to health and safety, as required by the military or veterans administration, national security, inmates, workers’ compensation.
Right to inspect and copy, right to amend, right to an accounting of disclosures, right to request restrictions, right to request confidential communications, right to a paper copy of this notice.
We reserve the right to change this notice. We will post a copy of the current notice in our facility with the current effective date.
If you believe that your privacy rights have been violated you may file a complaint with us. All complaints must be in writing.
We will request that you sign a separate form acknowledging you have received a copy of this notice. This acknowledgment will become part of your records.
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.
Please Indicate if whether you had any of the following medical problems.
(Include dates to indicate when the problem occurred.)
Your information will be encrypted.