Child Authorization for Release of Information | Huntersville Smiles Step 1 of 2 50% Authorization for Release of InformationHuntersville Smiles Orthodontics is authorized to release protected health information about the below-named patient in the following manner and to identified person.Patients’ Name * Required First Middle Initial Last Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Name * Required First Last Relationship to Patient * Required Mother Step-Mother Father Step-Father Guardian Authorization of ReleaseHuntersville Smiles Orthodontics is authorized to release protected health information about the below-named patient in the following manner and to identified person. I understand the following information including but not limited to appointment, medical, treatment and financial details may be discussed via whatever form of communication I list below. I understand E-Mail and Text communication may not be sent in an encrypted manner and there is a risk it could be accessed inappropriately. I still elect to receive email and/or text communication. Who can Huntersville Smiles Orthodontics provide information on your behalf?Name * Required Relationship to Patient * Required Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail) * RequiredEmail * Required Add another contact? * Required Yes No Name Relationship to Patient Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail)Email Add another contact? Yes No Name Relationship to Patient Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail)Email Add another contact? Yes No Name Relationship to Patient Mother Step-Mother Father Step-Father Guardian Phone (SMS/Voicemail)Email Patient RightsI have the right to revoke this authorization at any time by contacting our office at (704) 850-6896. I may inspect or copy the protected health information to be disclosed as described in this document. Revocation is not effective in cases where the information has already been disclosed but will be effective going forward. Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. The information is released at the patient’s request and this authorization will remain in effect until revoked by the patient. Signature of Parent/Guardian * Required Reset signature Signature locked. Reset to sign again Please provide signature for Authorization of Release.
