Anne La Valle - Midwestern University Clinics

Patient Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Address *

Address

Requested Information / Documents

Type of Documents *

Dental Records

Radiographic Images

Photographs

OtherOther

Dental Document Details

HIV / AIDS diagnosis, treatment or testing information

Behavioral Health Notes

Alcohol or drug abuse treatment information

Authorization

This authorization will expire 1 year from 11/14/2018.

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.

Alcohol and Drug Abuse Treatment.
To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.

HIV / AIDS Information
To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.

Behavioral Health Notes / Record
I authorize the disclosure of any behavioral health notes or information in my medical record.

With my digital signature below, I consent to the release of the above listed information / documents.

Authorized Digital Signature *

Date Authorized *

Practice Areas

Anne La Valle, D.D.S.