Upland CA Orthodontic

Patient Information

I hereby authorize release of any information to other health care providers, insurance companies and business associates including personal health information, as well as administrative data which is not strictly dental or medical in nature. I additionally authorize payment of insurance benefits directly to Dr. Gray Orthodontic Specialists.
I am giving my consent to use and disclose my protected health information to carry out treatment, payment activities and health care operations. (A complete version of our HIPAA can be viewed on our website.)
I certify that the information on this form is complete and true to the best of my knowledge. I understand that where appropriate, credit bureau reports may be obtained.

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