Packard Family Dentistry New Patient Form

Limited Patient Authorization for Disclosure of Protected Health Information
Patient Name

Last Name First Name
Date of Birth

Month Day Year
Date
SSN Number (last four digits)
Entity requested to Release Information: Packard Family Dentistry

Purpose of request (who will be authorized to receive information) - I authorize the entity listed above disclose or provide protected health information, about me to the individual listed below.
Name

Last Name First Name
Phone
Please enter a valid phone number.
Email
example@example.com
Name

Last Name First Name
Phone
Please enter a valid phone number.
Email
example@example.com
Secure Communication - Note that regular email is not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not designate email if this is a concern to you.
Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the person(s) identified above:

Entire patient record: or, check only those items of the record to be disclosed: Office Notes Treatment Lab results X-rays Financial/insurance reports Appointment(s) history/future
This authorization will expire at the end of the calendar year, unless you specify an alternate date. You must submit a new authorization form after the calendar year to continue the authorization. Please list the date of expiration if other than the end of the calender year _____________________

You have the right to terminate this authorization at any time by submitting a written request. Termination of this authorization will be effective upon written notice, except where a discussion has already been made based on prior authorization.

We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.
Patient Signature or authorized representative signature *

Clear
Date

Month Day Year
Date
Should be Empty:

PATIENT REGISTRATION

PERSON RESPONSIBLE FOR ACCOUNT

INSURANCE INFORMATION

MEDICAL HISTORY

DENTAL HEALTH AND APPEARANCE

COSMETIC/ESTHETIC EVALUATION

Limited Patient Authorization for Disclosure of Protected Health Information