Emergency Contact and Authorization for Release of Health Information Form

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Emergency Contact and Authorization for Release of Health Information

"*" indicates required fields

Patient Information

Patient's Name*

First Last

Patient's Date of Birth*

Emergency Contact Information

Emergency Contact's Name*

First Last

Relationship*

Phone*

Address*

Street Address City State ZIP Code

Authorization for Release of Health Information

Many of our patients allow family members such as their spouse, parents or others to obtain dental or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental or billing information released to family members you must sign this form. Submitting this form will only give information to family members indicated below.

I authorize Cirocco Dental Center to release my medical and/or billing information to the following individual(s):

Name

First Last

Relationship

Name

First Last

Relationship

Name

First Last

Relationship

My Information and Consent

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Phone

This field is for validation purposes and should be left unchanged.

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