backcovedental.com - AUTHORIZATION TO RELEASE PROTECTED HEALTHCARE INFORMATION

AUTHORIZATION TO RELEASE PROTECTED HEALTHCARE INFORMATION
I, Type a label , give Steven S. Shaw, D.M.D., and/or his authorized employees’ permission to release my dental records or summaries of pertinent treatment information to:
I understand that Steven S. Shaw, D.M.D. is not responsible for the management of these records once they are no longer in his possession.
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Notice: Steven S. Shaw D.M.D., P.C., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, or age. If you speak English, the language assistance services are complimentary. (French): Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.(Spanish) : si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
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