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):
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.