Verbal Disclosure Authorization Form Eligibility Determination for Sliding Fee Discount Your privacy and confidentiality are important to us. St. George Medical Clinic does not verbally release any information regarding care or test results to anyone other than the patient, unless otherwise specified. Please indicate below, the name and relationship to you of the person (spouse, mother, sister, etc.) to whom we may release such information if necessary. Otherwise, we will refuse any face-to-face interactions or calls requesting this information. You may revoke this authorization in writing/online submission at any time. Note: We may use and disclose your health information as it relates to your treatment, payments for services, and our operations as indicated in our HIPPA Privacy Policy. By signing this form, you authorize us to release verbally any information regarding your care or test results to the individual(s) named below: Person(s) Authorized to Receive Information HIPPA Information I, , have received a copy of the St. George Dental Clinic's HIPPA Privacy Policy and understand its meaning.
