Waukesha Family Dentistry - HIPPA Authorizations Form

HIPPA Authorizations

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.

Patient Name(*)

Please provide the patient or guardian's full name.

I authorize Drs. Shoemaker & Gilson to release my dental information to:

Name of Contact

Invalid Input

Relationship to Patient

Invalid Input

Contact Phone

Please enter valid phone number (xxx-xxx-xxxx)

Check here to add another contact. Invalid Input

Name of Contact

Invalid Input

Relationship to Patient

Invalid Input

Contact Phone

Please enter valid phone number (xxx-xxx-xxxx)

Please choose one:(*)

I understand that checking this box constitutes a legal signature confirming that I authorize the release of my information as described above.

I do NOT authorize the release of my information to anyone.

You must choose one of the authorization options to submit this form.

Authorization to Leave Messages with Household Members/Answering Machine

From time to time it may be necessary for an employee of Drs. Shoemaker & Gilson to leave messages for patients regarding their care. At no time will a representative discuss your dental circumstances or conditions without your consent. The purpose of this consent is to obtain your authorization to leave a message with a member of your household or on your answering machine, which may or may not be confidential.

You have the right to revoke this consent, in writing, except where we have already made disclosures on your prior consent.

Please choose one:(*)

I understand that checking this box constitutes a legal signature confirming that I authorize employees of Drs. Shoemaker & Gilson to leave a message with a member of my household or on my answering machine.

I do NOT authorize the leaving of messages.

You must choose one of the authorization options to submit this form.

Electronic Signature(*)

Sign Above

Please provide an electronic signature.