I hereby authorize and consent for Dr. Angie Dinh D.D.S. to release any and all medical, dental, and/or psychological reports or records, including, but not limited to, medical/dental notes, physician narratives, office notes, operative notes, discharge summaries, Doctor's/Dentist's orders, Nurse's notes, lab reports, test results, physical therapy progress notes, patient progress reports, diagnosis, post-operative reports, post-operative diagnosis, pathology reports, x-rays, MRIs, any records reflecting treatment for substance abuse, mental illness, AIDS, HIV virus, alcohol abuse, including any x-rays, diagnostic studies, laboratory slides, clinical abstract, histories, charts, and other information contained therein, any documents and opinions relevant to past, present, or future physical and mental condition, treatment, care or hospitalization, and any other personal health information regarding my medical or dental care as necessary to carry out treatment, obtain payment, and/or conduct other healthcare operations. The release of the matters listed above is being authorized for purposes of obtaining medical/dental treatment, payment for such services and other health care operations.
A copy of this authorizations is agreed by the undersigned to have the same effect and force as an original.
Any person, firm, or entity that releases matters pursuant to this authorization is hereby absolved from any liability.
I FURTHER UNDERTAND THAT I HAVE READ THE NOTICE OF PRIVACY PRACTICES AND UNDERSTAND MY RIGHTS TO MY HEALTH INFORMATION AND MAY REQUEST RESTRICTIONS. I FURTHER UNDERSTAND THAT I MAY REVOKE THIS CONSENT IN THE FUTURE IF I SHOULD SO DESIRE.