Authorization to Release Information to Family Members
Many of our patients allow family members such as their spouse, parents, or others to call and request personal information regarding dental treatment. Under the requirements of HIPPA, we are not allowed to give this information to anyone without the patient's written consent. If you wish to have your dental information released to family members you must sign this form. Signing this form will only give consent to release dental information to the family members indicated below. This consent form will not allow Drs. Shoemaker & Gilson to release any other information to these family members.
You have the right to revoke this consent, in writing, except where we have already made disclosures on your prior consent.