MEDICAL RELEASE FORM

Thank you for choosing Dr. Ben Johnson as your dentist. All new patients must complete the form below.

COMMUNICATION / MEDICAL RELEASE FORM

Full Name *

The Privacy Rule generally requires healthcare providers to take reasonable steps to minimize the protected health information (PHI) requests, usage and disclosure for only what is required to meet the intended need. These provisions do not apply to uses. *

AUTHORIZED REPRESENTATIVES

I give permission to receive my health information regarding diagnosis, treatment, billing, and appointments.

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I give permission to share the following:

Appointments

Billing

Discuss my treatment and diagnosis

Name

Relationship

I give permission to share the following:

Appointments

Billing

Discuss my treatment and diagnosis

Name

Relationship

I give permission to share the following:

Appointments

Billing

Discuss my treatment and diagnosis

Please read the following statement and sign below if you agree.

I have read the Privacy Notice and understand my rights contained in the Notice. By way of my signature, I provide this practice with authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.

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Call Us For An Appointment

Phone: (270) 554-2432

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Working Hours

Monday-Thursday 8am-5pm
Friday – By appointment only.

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Our Address

2913 Lone Oak Rd
Paducah, KY 42003

Website by: Website Design Works Paducah