Privacy Practices. I hereby authorize the release of all medical information necessary to process my claims and I authorize release of this same information, when necessary, to other providers rendering medical/dental care, as well as to labs that need my information to make a diagnosis, treatment and/or fabricate an appliance necessary for my treatment. I acknowledge receipt and agree for my information to be provided or obtained for processing of insurance claims; when releasing or requesting medical information to insurance companies or your provider needed for the processing of your claims and treatment; release and use of photographic documentation for educational and research purposes.
Appears in 4 contracts
Samples: Private Patient Agreement, Private Patient Agreement, Private Patient Agreement
