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    Drs Horton & Vranas, INFORMATION RELEASE AND AUTHORIZATION FORM


    AUTHORIZATION FOR RELEASE OF INFORMATION




    I authorize the release of information including the entire contents of dental record, including diagnosis, treatment details and financial information.



    This information may be released to:



    Spouse
    Child(ren)
    Other
    Information is not to be released to anyone

    I understand that I have the right to revoke this Authorization, in writing, at any time by notifying this office. Such revocation will not affect actions taken by the requesting person prior to the date he or she received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be protected by this rule. I understand that my dental provider cannot condition treatment on whether I sign this Authorization.

    This Authorization will remain in effect until terminated by me in writing or until the following date:

    MESSAGES

    Please call:
    my homemy workmy cell

    If unable to reach me:

    You may leave a detailed message
    please leave a message asking me to return call
    Other

    I agree to two way text messaging with Horton & Vranas DDS until I inform them to STOP.

    It is my responsibility to notify Drs Horton & Vranas of changes and to complete a new form.

    In lieu of signature please place the first letter of the city you were born in.
     
    Date



    Patient/Authorized Person (Please Print)
     



    Relationship to Patient
     


    AUTHORIZATION FOR TREATMENT OF A MINOR BY DELEGATED PERSONS

    I hereby authorize that the following persons have my permission to seek and authorize dental treatment of the above named minor child in my absence and that his/her protected dental information may be shared.

    Name:
    Relationship to Patient
    Phone Number:

    Name:
    Relationship to Patient
    Phone Number:

    It is my responsibility to notify Drs. Horton & Vranas of changes and to complete a new form.


    In lieu of signature please place the first letter of the city you were born in.
     
    Date

    Patient/Authorized Person (Please Print)
     

    Relationship to Patient