Adult Authorization for Release of Information | Riverbend Orthodontics Step 1 of 2 50% Authorization for Release of InformationRiverbend 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 * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Authorization of ReleaseRiverbend Orthodontics is authorized to release protected health information about the 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 above. 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. How can Riverbend Orthodontics communicate with you?Email * Required Phone (Mobile/SMS) * RequiredPhone (Voicemail) * RequiredOther Who can Riverbend Orthodontics provide information on your behalf?Name Relationship Phone (SMS/Voicemail)Email Opt-Out Only select if you do NOT want any information released to family or friends.What information may we share with this person? Medical/Treatment Financial Appointment Details Patient RightsI have the right to revoke this authorization at any time by contacting our office at 704-234-7774. 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 Patient * RequiredPlease provide signature for Authorization of Release.
