Kathryn B Miller, ODHarvard Medical School Department of 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and date of birth in the designated fields at the top of the form.
3. In the authorization section, select whether you authorize Dr. Miller to disclose, obtain, or exchange information by checking the appropriate boxes.
4. Fill in the name and contact details of the person or organization with whom information will be exchanged.
5. Indicate how the information will be used by checking relevant options such as treatment planning or coordination of care.
6. Specify any additional information that may be disclosed by selecting from the provided list or writing in your own description.
7. Complete the expiration date for this authorization or specify an event that relates to its use.
8. Sign and date the form at the bottom. If applicable, a parent or legal guardian must also sign if the patient is under 18 years old.

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