Patient Information Authorization Form | Shelby Township Dentists

Patient Name*

First Last

Date of Birth*

Address*

Street Address City State ZIP Code

Consent*

I hereby authorize the use and disclosure of the patient information as described below. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA privacy regulations.

Patient information to be used or disclosed: (Please check which apply)*

Appointment information
Any information related to our dental office
Account information
Treatment Information

Consent*

I authorize Dr. Jeffrey T. Baker and staff to make this use or disclosure to the following person(s) listed below

The following person(s) may receive this patient information:

Person 1

Person 1: Relation to patient

Person 2

Person 2: Relation to patient

Person 3

Person 3: Relation to patient

Patient Signature*

Date*