NOTICE OF PRIVACY PRACTICE FORM Consent to release Protected Health Information (PHI) I understand that in order to disclose my PHI, Smiles by Morel must have my consent; therefore, I authorize Smiles by Morel to disclose my PHI as described in the above forms to the recipients listed below. Description of the information to be disclosed (check all that apply): All Procedures Test Results Appointments Other Surgeries Billing/Account information Name(s) of the person(s) authorized to obtain the above mentioned information (e.g., physician other than your referring doctor, family members, and other specified person/persons):Name Relationship Name Relationship Name Relationship Name Relationship Contact Information: l authorize Office Name to contact me at the following number with results or questions: Home Cell Work May we leave a detailed message on your answering machine or voicemail? Yes No Failure to check one of these boxes may delay resultsBy Patient: (Print and sign) Date Or Patient's Representative (Print name, sign and describe authority) Date Form expires one year from signature date.CAPTCHA Δ
