broadwayoralsurgery 136e.broadway belair,md21014 (410)838 … · 2019. 1. 2. ·...
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![Page 1: BroadwayOralSurgery 136E.Broadway BelAir,MD21014 (410)838 … · 2019. 1. 2. · BroadwayOralSurgery 136E.Broadway BelAir,MD21014 (410)838-6222 IauthorizeBroadwayOralSurgerytodisclosemyProtectedHealthInformation(includingbut](https://reader035.vdocuments.mx/reader035/viewer/2022070214/6111c45906e07a669300f5e4/html5/thumbnails/1.jpg)
Broadway Oral Surgery136 E. BroadwayBel Air, MD 21014(410) 838-6222
I authorize Broadway Oral Surgery to disclose my Protected Health Information (including butnot limited to, prescriptions, test results, appointment information and medical records), to thefollowing individuals:
Name: _______________________________ Relation: _______________________________
Name: ______________________________ Relation: _______________________________
Name: _______________________________ Relation: _______________________________
Name: ______________________________ Relation: _______________________________
Print Patient Name: ____________________________________ Date of Birth: __________________
Patient Signature: ______________________________________ Date: ________________________
Witness: ________________________________________________
Are we permitted to leave results on an answering machine/voicemail? YES ______ NO ________
If YES please provide preferred phone number: _____________________________________________
This form must be updated by the patient annually or whenever there is a change in authorization status.
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