Request and Authorization To Release Health Information

Request And Authorization To Release Health Information

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Request And Authorization To Release Health Information

SECTION I. PATIENT INFORMATION

Patient Name(Required)

First Middle Last

Date of Birth(Required)

Social Security Number(Required)

Address(Required)

Address City State ZIP / Postal Code

Home Phone

Cell Phone

SECTION II. INFORMATION REQUESTED

By signing this Authorization, I acknowledge and agree that Highpoint Dental Care (the “Practice”) may use or disclose my Protected Health Information for the purpose and to the extent that I indicate below (Check all that apply):

Complete medical record

Health care information in my medical record relating to the following treatment or condition:

Health care information in my medical record for the date(s):

Other, i.e. x-rays, bills (specify dates):

SECTION III. RECIPIENT AND PURPOSE

I authorize the Practice to disclose the protected health information, as indicated above, to:

Name(Required)

First Last

Organization/Entity

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Fax

This protected health information is being used or disclosed for the following purpose:

Transfer of records to another provider

Transfer of records to complete health records at another entity

Insurance claims information

Personal use

Other

Other (describe)

I understand that I may change my mind and revoke this Authorization in writing at any time by notifying the Privacy Officer, 3574 S. Tower Rd., Ste. B, Aurora, CO 80017 fax 303-617-9100. The revocation will not apply to the extent that the Practice has already taken action where it relied on my permission. I have the right to inspect or copy my Protected Health Information and request amendments where appropriate.

This Authorization shall expire sixty (60) days after the date below, unless I state a different expiration date here:

The Protected Health Information used or disclosed as a result of this Authorization may be redisclosed by the recipient and no longer protected under federal privacy regulations. I understand that I may refuse to sign this Authorization, and if I do refuse, my ability to obtain treatment will not be effected. By signing below, I authorize the Practice to use or disclose my Protected Health Information as specified in this Authorization.

Signature (Patient)(Required)

Date(Required)

Print Name(Required)

If this Authorization has been signed by a personal representative on behalf of an individual (for example, the parent or guardian of a minor), his/her authority to act on behalf of the individual must be set forth here: