Privacy and Signature Release Form

SECTION A: The Patient.

Name:

Telephone #:

Address:

City:

State:

Zip:

Email:

Patient Number:

Social Security Number:

SECTION B: Acknowledgement of Receipt of Privacy Practices Notice

I, (State Name Below) acknowledge that I have received a Notice of Privacy Practices from the above-named practice.

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.

Signature:

Date:

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

Personal Representative's Name:

Relationship to the Individual:

Your signature is necessary for us to:

Process all Insurance Claims
To ensure payment for services rendered
To release medical information to insurance companies
To release information to other medical/dental providers, when necessary, for you treatment
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.

Patient:

Responsible Party:

Date

Your information will be encrypted.