DECLARARTION  DENTAL
                        Dr. Mark A. Riese D.D.S., P.C.
CONTACT INFORMATION FOR PROTECTED HEALTH INFORMATION 
	I, 	, Date of Birth: 	, request that 
the following be followed for the disclosure of my Protected Health Information. Protected Health 
Information would include your name, diagnosis(es), tests results, dates of service. 
PLEASE CHECK ALL THAT APPLY 
You may disclose information to my family members and or non-family members. Please list 
name, phone number, and relationship. 

Name 

Phone Number 

Relationship 

			

 You may leave Protected Health Information on my answering machine/voicemail. 
Phone Number: _______________________
 Other:  You may disclose insurance information to a referring dental office. 

I have received a copy of the office’s Notice of Privacy Practices.

Patient's Signature: 
________________
Patient's Printed Name ___________________

Date: 
___________________ 
Parent's Signature (if minor) 

___________________________________