PATIENT AUTHORIZATION FORM

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents, or children to call and request the results of tests, procedures, and financial information. They also allow family members and caregivers to call to book/reschedule or cancel appointments. Under the requirements of the Personal Health Information Protection Act (PHIPA), we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, diagnostic test results, and/or financial information released to any family members, or if you wish to have a family member or caregiver contact the office on your behalf, you must sign this form.

You have the right to revoke this consent in writing, except where we have already made disclosures based on your prior consent.

I authorize Ottawa Valley Denture Clinic (OVDC) to release my records and any information requested to the following individuals. I further allow OVDC to communicate with the following individuals regarding information about my appointments.

Please write the names of any person we are authorized to share information with, as mentioned above: (Example: Spouse, Son/Daughter, Caregiver etc.) (Click the + to add lines)

Name	Relation to Patient

Authorization Regarding Messages

Please check all that apply

I authorize you to leave a detailed message on my home or cell number regarding appointments.
I authorize you to leave a detailed message on my home or cell number regarding medical treatment, care, or test results
I authorize you to leave a message with anyone who answers the phone.

Messages may only be left with:

First Last

Patient Name*

First Last

Patient Signature

Phone

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