Hipaa Release Form

  • ALL ALASKA ORAL & CRANIOFACIAL SURGERY
    HIPAA Release Form

    • I authorize the release of information including diagnoses and records; examinations rendered to me and claims information.

    • This information may be released to:

    • Related Care Providers, except

    • Information is not to be released to:

    • This Release of Information will remain in effect until terminated by me in writing.

    • Patient Privacy Practices Acknowledgement

      I, the undersigned, do hereby consent and agree that I have received a copy of the Patient’s Right to Privacy Policy or have declined at this time.

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