To use or disclose your protected health information in such cases, our office must receive prior written authorization from you, the patient. Our office may not condition treatment, payment, enrollment or eligibility for benefits on whether you sign this authorization.
The purpose for which our office is requesting your authorization is as follows:
For permission to insurance companies for direct payment and prior approval of dental work, if needed.
The information to be disclosed would be as follows:
For dental work only.
The information will be disclosed to the following entity:
For referral to Dental Specialist(s), Physician(s) and Insurance Payment Centers.
By agreeing to this authorization, you understand that the potential for information to be disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by the privacy regulation of HIPAA. You also understand that you are entitled to receive a copy of this authorization form.