Patient Registration

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

Patient's Name

Date of Birth

The last four digits of your Social Security Number

Patient's Mailing Address

Telephone Number

Information To Be Disclosed

I authorize HMH Oral and Maxillofacial Surgery Department to disclose my health information as follows, for service dates

Health Information

Entire Medical Records or Outpatient Clinical Records

History and Physical(s)

Operation Report(s)

Discharge Summary

Films

Pictures

Laboratory Results

Radiology and Imaging Reports

Other Test Results

Pathology Slides Blocks or Reports

Other Health Information

Other Test Results

Other 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

Purpose of use or disclosure:

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

This authorization is valid for 180 days unless otherwise stated here:

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.

Printed Name of Qualified Personal Representative:

Legal Documentation Showing Authority to Act on Behalf of the Patient:

disregard this

Document Signers

- Signer