Patient Authorization for Release of Health Information

Please fill out this form prior to the initial exam at Petaluma Orthodontics so insurance and dental information can be released to our office for exam and treatment use.

The completion of this document authorizes the disclosure of an individual’s protected health information as set forth below, consistent with California and Federal Laws. Failure to sign and provide all information requested will result in the non-release of protected health information.

authorize the release of records for

TO: Provider Name/Organization
Petaluma Orthodontics
Address of Provider
301 Washington Street
Petaluma, CA 94952
Provider Phone Number
Provider Email
Provider Fax

Reason for request/use of health information.
Switching Orthodontists
Orthodontic Use
Information requested for:
Treatment Records
Insurance Information
Dental X-rays

I understand that:
  1. A. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to my orthodontist I am aware that if I chose to later revoke this authorization and my orthodontist has already processed the original request to release this information, revocation will not be effective.

  2. B. If I authorize my/my child’s protected health information to be disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re-disclosed and would no longer be protected.

  3. C. I have the right to inspect and receive a copy of my/my child’s own protected health information to be used or disclosed, in accordance with requirement of the federal privacy protection regulations found in the Privacy Act.
I request and authorize the release of information described above to the named individual/organization indicated.
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707-762-0211 • 301 Washington Street, Petaluma, CA 94952 •