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AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION TO DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY


Information To Be Disclosed

Health Information

I understand that information used or disclosed pursuant to this authorization form may include information relating to Human Immunodeficiency Virus (HIV), or Acquired Immunodeficiency Syndrome (AIDS); treatment for or history of drug or alcohol abuse; or mental or behavioral health or psychiatric care.

 

Information is to be disclosed to:

Alfi Oral, Dental Implant & Facial Surgery

6624 Fannin St, Ste 1710,

Houston, TX 77030

(844) 253-4667



I authorize the disclosure of health information as described above. I understand the following:

  • A photocopy or fax copy of this authorization is as valid as the original.
  • I may revoke this authorization, but the revocation will not apply to information that has already been
  • released in good faith before the revocation was received.
  • Treatment or payment may not be conditioned on my completion of this authorization form.