Hagerstown Community College Dental Education Clinic Designation of Individuals Who are Involved in my Payment or Treatment Decisions
I hereby authorize employees of the HCC Dental Education Clinic to disclose my protected health information and related treatment and/or payment information for health services received to the individual(s) (i.e. family members, doctors’ offices, etc.) who I have indicated below. *Please enter the designated individual(s) information and check the appropriate box to indicate whether the individual is involved in your payment and/or treatment decisions.
Individual’s Full Name
Relationship to
Involved in
Involved in
(Please print)
Patient
Payment
Treatment (Check if yes)
(Check if yes)
This information will be presumed valid and the HCC Dental Hygiene Clinic may rely on it until you have submitted written notification stating changes in individual designation. Notification of a change should be sent to: The HCC Dental Hygiene Clinic, ATTN: Clinic Manager, 11400 Robinwood Drive Hagerstown, MD 21742-6514.
Patient or Legal Representative
Signature Date
White- HCC File Copy Yellow- Patient Copy
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