Verbal Communications

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Ballard Dental Associates, Inc.

Robert W. Davis, D.D.S., Christopher Alley, D.D.S. & Andris Kirsis, D.D.S.

408 Campus Dr., Suite A, Huxley, Iowa 50124

(515) 597-5300

AUTHORIZATION FOR VERBAL COMMUNICATIONS

Patient's Name:

Date of Birth:

Street Address:

City:

State:

Zip:

I permit Ballard Dental Associates personnel to discuss health and/or billing information, in person or by telephone, with the following family members or friends involved in my medical care. (List family members/friends and state the person's relations to the patient.)

Release of information under this document is limited to verbal discussions with Ballard Dental Associates. This document does not permit release of any written health information to the individuals named below.

The authorization is limited to discussions regards the following medical condition(s) or timeframe(s):

If no limitations are listed, discussions will be permitted regarding any medical condition for which the patient has received care.

Name:

Phone:

Relationship to Patient:

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If, at any time, I do not want verbal discussions to be permitted between Ballard Dental Associates and any of the individuals named above, I must notify Ballard Dental Associates Business Office.

Patient's Signature:

Print your name.

Draw your signature.

Clear Signature

Date:

Representative's Name:

Date:

Relationship to Patient:

Ballard Dental Associates

Verbal Communications

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