• 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.

  • 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):

  • Contact Information:

    l authorize Office Name to contact me at the following number with results or questions:

    Failure to check one of these boxes may delay results

  • Form expires one year from signature date.