2525 K Street, Suite 108 Sacramento, CA
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About
Meet Dr. Rho
Meet the Team
Tour Our Office
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Patient Info
FAQ
Patient Registration
Testimonials
Schedule an Appointment Online
Financial Policy
Whitening For Life Program
Healthy Smiles Program
Blog
Patient Appreciation
Covid-19
Patient Screening Form
Individual Entry Protocol
Preventive
Cleanings, Exams & X-Rays
Oral Cancer Screening
Periodontal Health
Snoring and Sleep Apnea
Teeth Grinding (Bruxism)
Cosmetic
Invisalign
Invisalign for Teens
Dental Implants
Single Tooth Implant
Porcelain Veneers
Porcelain Fixed Bridges
Teeth Whitening
Multiple Tooth Implant
Restorative
Composite Fillings
Dentures
Bridges
Crowns
Bonding
Root Canals
Crown Lengthening
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Patient's Full Name:*
Patient's Date of Birth:*
Requested By:*
PATIENT
PARENT/LEGAL GUARDIAN
PERSONAL OR LEGAL REPRESENTATIVE OF THE PATIENT
[Optional] If the requestor is NOT the patient, the following Requestor Information is REQUIRED:
Requestor's Full Name:
Requestor's Address:
Requestor's Telephone Number:
Authorization Approval:*
I HEREBY AUTHORIZE RHO FAMILY DENTISTRY TO RELEASE INFORMATION CONTAINED IN THE HEALTH RECORD OF THE PATIENT'S FULL NAME INDICATED ABOVE.
Email Security Acknowledgement:*
PLEASE SEND REQUESTED RECORD VIA UNENCRYPTED EMAIL. I RECOGNIZE THAT EMAIL IS NOT A SECURE FORM OF COMMUNICATION. THERE IS SOME RISK THAT ANY INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION AND OTHER SENSITIVE OR CONFIDENTIAL INFORMATION THAT MAY BE CONTAINED IN SUCH EMAIL MAY BE MISDIRECTED/DISCLOSED TO/INTERCEPTED BY UNAUTHORIZED THIRD PARTIES.
Email address to where Rho Family Dentistry can send records:*
Any and all information may be released including, but not limited to, mental health records protected by the Lanterman-Petris-Short Act, drug and/or alcohol abuse records and/or HIV test results, if any except as the patient has specifically provided below
[if none - please write "none"]
Release Exclusions:*
This authorization is effective now and will remain in effect until
[insert date below]
. I understand that I may receive a copy of this authorization.
Effective To Date:
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Rho Family Dentistry
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Rho Family Dentistry, 2525 K Street, Suite 108 Sacramento, CA 95816 ~ (916) 562-2755 ~ rhofamilydentistry.com ~ 1/19/2023 ~ Tags: dentist Sacramento CA ~