Forms & Insurance - Chehalis WA Dentist
Return to the Goldsby Family Dentistry Main Page  
Dental Staff Chehalis WA Dental Services Chehalis WA Contact About Us
   
This web site is protected by SSL (Secure Sockets Layer). SSL allows sensitive information such as credit card numbers, social security numbers, and login credentials to be transmitted securely.


Trisha T Goldsby D.D.S., P.S.
388 SW 13th St. / P.O. Box 120
Chehalis, WA 98532


Authorization to Duplicate, Use,
or Disclose Protected Health Information
Patient/Member, Parent or Personal Representative Request
Describe Purpose:


Patient/Member Information
Name:
Address:
City:
State:
Zip:
DOB:
Phone:
Send to:
Dr. Mr. Ms.
Name:
Address:
City:
State:
Zip:
Phone:
Description of Information: (describe records to be duplicated or specific use or disclosure requested)


I authorize Dr. Trisha Goldsby's dental office to duplicate, use or disclose my protected health information as described above. Authorization will expire in 90 days unless I revoke it earlier by written request sent to Dr. Goldsby's address. The member/patient, parent or personal representative must sign this Authorization.
Description of representative's authority: (parent/guardian/etc.)

   
  did you know?
 

• People who drink 3 or more sugary sodas daily have 62% more dental decay, fillings and tooth loss.

• The average person only brushes for 45 to 70 seconds a day, the recommended amount of time is 2-3 minutes.
- Academy of General Dentistry

  Design by Sanders Design