Krystal Teague DentalHIPAA Authorization for Use or Disclosure of Health Information or Financial Information*Required Field Patient's Full Name* Date of Birth* By checking this box, I authorize Krystal Teague Dental to disclose information in relation to my account and/or appointments to the following source(s) of contact. By signing below, I also give permission for Krystal Teague Dental to contact me via... (select all that apply) EmailPersonal PhoneWork PhoneText Messages Protected Health Information (PHI) Disclosure to Family Members You may authorize us to contact a family member regarding your medical and financial matters. This is to acknowledge that you authorize Krystal Teague Dental to disclose your PHI to the following individuals. Name Relationship to Patient Phone Types of Information: (select all that apply) AppointmentsRemindersHealth InformationFinancial Information Name Relationship to Patient Phone Types of Information: (select all that apply) AppointmentsRemindersHealth InformationFinancial Information Name Relationship to Patient Phone Types of Information: (select all that apply) AppointmentsRemindersHealth InformationFinancial Information Acknowledgement of Receipt of Notice of Privacy Practices Krystal Teague Dental is committed to protecting your privacy. We will not release any information about you or your treatment without your consent. Only the people you listed above will be authorized to receive your information. I have been given a copy of Krystal Teague Dental's Notice of Privacy and offered a copy to take home.
