Phone: 770.925.3300 | TeboDental.com

Patient Authorization to Release Information

The patient authorizes Tebo Dental Group to release the patient’s protected health information as follows:

*Patient name:

*Date of birth:

*I am authorizing the release of my protected health information for the following purpose:

*Special circumstances (if none, so state):

Health information to be released (please check all that apply):

Dental records (excluding x-rays, unless “X-ray duplicates” also checked below)

X-ray duplicates

Billing records

School Form 3300

School excuse

Other:

Health information to be withheld (if any):

Release health information to:
Delivery of health information (check only one):

Hold for pick up by:

Fax to (fax no.):

Mail to (address):

Email to (address):

This Authorization will expire (if no expiration given, this Authorization will expire one (1) year from the date of signing):

I understand that I have the following rights: I can revoke this Authorization at any time by giving my oral or written revocation to Tebo Dental Group. My revocation will not be effective for any disclosures already made or any actions already taken in reliance on this Authorization. Tebo Dental Group may not condition treatment, enrollment in any health plan or eligibility for any benefits on whether or not I sign this Authorization. I am authorizing disclosure of information protected under federal law. This information, once disclosed, may be subject to re-disclosure by the recipient and may no longer be protected by federal law. I have received a copy of this Authorization.

*Signature of patient or Parent/Guardian

Date signed:

*Signed by:

Parent/Guardian

Patient

*If signed by the patient’s Parent/Guardian, basis of Parent/Guardian’s authority:

*Parent/Guardian’s name:

*Phone:

*Parent/Guardian’s address: