AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION TO DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
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
Houston, TX 77030