Waiver to Discuss Treatment

Permission to Discuss Protected Health Information

(This form is for patients 18 & older)
Patient Name
Date of Birth

MonthDayYear
Date
Address
I give permission to Center Family Orthodontics (Dr. Jaimie Vassiliou and her staff) to discuss the following medical/dental and financial information about me:
Type a question

Medical/dental information pertaining to my orthodontic treatmentInsurance informationBilling/ payment informationOther
Center Family Orthodontics (Dr. Jaimie Vassiliou and her staff) have my permission to discuss the above information with:
Name
Relationship
Address
Home, cell, or work
Email
example@example.com
Name
Relationship
Address
Home, cell, or work
Email
example@example.com
Name
Relationship
Address
Home, cell, or work
Email
example@example.com
I understand that I have the right to revoke my permission at any time except where Center Family Orthodontics has already made disclosures in reliance upon this request. I will notify Center Family Orthodontics in writing if I want to revoke my permission.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Permission to Discuss Protected Health Information