Privacy and Signature Release Form

Please correct the errors described below.

SECTION A: The Patient.

SECTION B: Acknowledgement of Receipt of Privacy Practices Notice

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

If a personal representative signs this authorization of behalf of the individual, complete the following:

Your signature is necessary for us to:

  1. Process all Insurance Claims
  2. To ensure payment for services rendered
  3. To release medical information to insurance companies
  4. To release information to other medical/dental providers, when necessary, for you treatment
  5. Get X-rays emailed to us from previous doctors

I authorize the release of all medical information necessary to process my claims and I authorize the release of this same information, when necessary, to other providers rendering medical/dental care. I assign all medical and surgical benefits, including major medical benefits in which I am entitled, to DR. LYSANDRO TAPNIO. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

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