Authorization for Disclosure of Health Information

Authorization for Disclosure of Health Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I authorize (provider Name/Organization)* to release information to Healthy Smiles for Kids of OC 10602 Chapman Ave Suite 200 Garden Grove CA, 92840 Phone #: 714-638-5993 Fax #: 714-638-5992*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Reason for Request*

Personal UseSchoolContinued Medical CareLegalInsuranceOther
Please mark all and acknowledge you have read the following and understand that*

A. I have the right to revoke this authorization at any time. My revocation must be in writing and provided to Healthy Smiles for Kids of Orange County (HSK). I am aware that if later revoke this authorization and HSK has already processed original request to release this information, revocation will not be effective.B. If I authorize my protected health information to be disclosed to someone who is notrequired to comply with federal privacy protection regulations, then such informationmay be re-disclosed and would no longer be protected.C. I have a right to inspect and receive a copy of my own protected health information to beused or disclosed, in accordance with requirement of the federal privacy protectionregulations found in the Privacy Act.
I request and authorize Healthy Smiles for Kids of Orange County to release the informationdescribed above to the named individual/organization indicated.
Signature of Patient/Parent/Legal Representative:

Clear
Date*

MonthDayYear
Date
Relationship to patient (if applicable) blanks
Should be Empty:

Authorization for Disclosure of Health Information

I request and authorize Healthy Smiles for Kids of Orange County to release the informationdescribed above to the named individual/organization indicated.