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 result of tests, procedures, and financial information. Under the requirements for 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, any diagnostic test results and/or financial information released to any family members you must sign this form.

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

I authorize this denture clinic to release my records and any information requested to the following individuals:

Name	Relation to Patient

(Click the + to add lines)

Patient Name*

First Last

Authorization Regarding Messages (please check all that apply)

Consent

I authorize you to leave a detailed message on my home or cell number regarding appointments

Consent

I authorize you to leave a detailed message on my home or cell number regarding medical treatment, care, or test results

Consent

I authorize you to leave a message with anyone who answers the phone

Messages may only be left with:

First Last

Patient Signature

Email

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