Many of our patients allow family members such as their spouse, parents, or others to call and discuss dental treatment, medical, insurance, or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your dental treatment, medical, insurance, or billing information released to family members, you must sign this form. Signing this form will only give consent to release this information to the family members listed below. This consent form will not allow Mystic Dental Group to release any other information to these family members.
You have the right to revoke this consent in writing.