PTI 3-web

This authorization will expire 1 year from 12/11/2023.

I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.

Community Partner site to email this completed form to communitypartners@midwestern.edu. Midwestern will
contact the patient to schedule an appointment within 48 business hours of receipt.

• Midwestern will reserve an appointment time for the patient. The length of time to complete your agreed upon
  treatment depends on the individual needs of each patient. As a teaching facility, care will require longer
  appointments than you may be accustomed to in a private dental office. Additionally, procedure completion may
  require more than one appointment. Valid ID is required for patient registration.
• Patient referral is valid for 30 days from date of referral on form and patient must be seen within those 30 days.
• If patient is taking medications, please remind them to bring a list to their appointment.
• Patient must be screened and accepted into the dental program prior to any treatment. For the no charge endodontic
  Community Partner therapy program, the patient will be provided with a limited exam and radiograph.
• Retreatments are not a covered benefit under the Community Partners endodontic therapy program.
• Some complex cases may be determined to be a non‐teaching case and outside the scope of the program.
• If patient does not require endodontic therapy, patient will be referred back to referring dentist for treatment.
• If patient is provided with endodontic therapy, the patient understands that treatment will include a restoration [core] to
  temporarily protect the tooth, at no charge to the Community Partner patient. Please note the tooth may still need additional
  definitive treatment.
• Patient understands that this referral is for potential limited treatment only for the listed tooth on the referral and the
  patient may choose to return for comprehensive care at our clinic.
• Patient must provide a current valid government issued photo ID.