For all states EXCEPT CA
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
T
his form is applicable for all states EXCEPT California.
May 2016
The Dental Practice will not condition treatment, payment, enrollment or eligibility for
benefits on providing, or refusing to provide this authorization.
Print Patient Name Patient Account Number
Address Date of Birth
City State Zip Code Email Phone
Doc
tor’s Name Practice Name
Pr
actice Address City State Zip
I hereby authorize the doctor and practice listed above to release the dental information of the patient
named above to:
Print Name of Recipient
Address City State Zip
Specify the dental information to be disclosed above.
Pu
rpose: The dental records and information disclosed may only be used for the purpose(s) listed above:
Duration: This authorization shall remain in effect for one year from the date of my signature below
unless a different date is specified here _________________ (date).
Revocation: You or your personal representative can revoke this authorization upon written request. If
you revoke, it will not affect information disclosed before the receipt of your written request to revoke.
Redisclosure: I understand that information disclosed pursuant to this authorization may no longer be
protected under federal privacy law (HIPAA) and could be re-disclosed by the recipient.
A copy of this authorization is as valid as the original. I have the right to receive a copy of this
authorization.
_____________ _______________________ _______________________________
Date Signature If Signed by Other than Patient,
Indicate Relationship
click to sign
signature
click to edit
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