Consent For Use And Disclosure Of Health Information - The Rector Dental Group Page 2

ADVERTISEMENT

Previous Dentist:______________________________________________Last Visit:_____________
Spouse's Name:_____________________________________________________________________
Single_______Married_______Divorced_______Widowed______
Your home address: Street______________________________City___________________
State_______________Zip_____________
Home Phone:__________________Cell Phone:________________Email address:________________
Occupation:_________________________________________________________________________
Name and address of business:________________________________________Phone #___________
Spouse's Occupation:_________________________________________________________________
Name and address of business:________________________________________Phone #___________
Person responsible for account:_________________________________________________________
CONSENT
I certify the truth of all information given. I authorize the release of pertinent information to
those persons requiring it for treatment, for the purpose of payment of the account, or credit references.
I hereby grant permission to Dr. Rector and/or legally qualified associates to perform those diagnostic
and treatment procedures, including local anesthesia, operative procedures, dental radiographs as may
be deemed necessary or advisable for the proper diagnosis and treatment.
Patient's Signature:______________________________________________Date:_______________
Witness:______________________________________________________Date:________________
THIRD PARTY PAYMENT INFORMATION
If your account is to be handled by any other method than direct payment to the office, please complete
the following section for our records. Your help with this information aids in expediting your dental
claim. Check one of the following:
Insurance:______________Medicaid:_______________
If Insurance:
Insurer's Name:___________________________________
Address:________________________________________
Social Security or Identification #____________________
Insurance Company:_______________________________
Place of employment:______________________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Consent For Use And Disclosure Of Health Information Consent For Use And Disclosure Of Health Information Legal
Acknowledgement Of Receipt Of Privacy Practices And Consent For Use And Disclosure Of Health Information Form Acknowledgement Of Receipt Of Privacy Practices And Consent For Use And Disclosure Of Health Information Form Business
Form Consent For Use And Disclosure Of Health Information Form Consent For Use And Disclosure Of Health Information Business
Authorization For Use And Disclosure Of Health Information Authorization For Use And Disclosure Of Health Information Medical
Consent To The Use And Disclosure Of Health Information Form For Treatment, Payment, Or Healthcare Operations Consent To The Use And Disclosure Of Health Information Form For Treatment, Payment, Or Healthcare Operations Legal
Authorization For Use And Disclosure Protected Health Information Form Authorization For Use And Disclosure Protected Health Information Form Medical
Hippa Authorization For Use Or Disclosure Of Health Information Hippa Authorization For Use Or Disclosure Of Health Information Medical
Authorization For Use Or Disclosure Of Health Information Authorization For Use Or Disclosure Of Health Information Business
Authorization For Use Or Disclosure Of Health Information Form Authorization For Use Or Disclosure Of Health Information Form Business
Authorization For Use Or Disclosure Of Health Information Authorization For Use Or Disclosure Of Health Information Medical

Related Categories

Parent category: Medical
Download
Go
Page of 5