Authorized Release of Medical Records

Authorization to Release Dental Record & Protected Health Information ("PHI") ("Authorization")
Patient name*
Last 4 Digits of SS#*
Address*

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone*
Date of Birth*

MonthDayYear
Date
Office*
I authorize Familia Dental / Vivid Smiles to release a copy of my dental record and/or Protected Health Information (described below) as defined under 45 CFR 164.501, the federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and applicable state laws to the following recipient:
Please send the records:*

To the patient and address above by mailSecurely by emailTo the person and address below:Via Fax to the number below:
Email
example@example.com
Name
Address
City, State, Zip
Phone
FAX Number
Please enter a valid phone number.
Reason for Records Request*
Record copy or Protected Health Information to be released:*

Entire Dental Record (including patient histories, office notes x-rays, referrals, consults, billing records, insurance records, and records received from other health care providers. I understand my complete health record may include information related to my mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse that I have provided to Familia Dental / Vivid Smiles.Dental Record for specific dates:Other:
Dental Record from

MonthDayYear
Date
Dental Record to

MonthDayYear
Date
Describe records requested:
By signing this form, I agree and acknowledge that:
- this Authorization is voluntary, and I am not required to sign it in exchange for receiving dental treatment.
- payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing this Authorization.
- information disclosed pursuant to this Authorization may be redisclosed by the recipient and no longer be protected by federal or state privacy laws.
- I have the right to inspect and receive a copy of the information used and disclosed pursuant to this Authorization.
- I have the right to revoke this Authorization at any time by writing to Familia Dental / Vivid Smiles, of my intent to revoke this Authorization. Returning this form, signed, dated and with the words "authorization revoked" is sufficient notice. However, I understand that such revocation will not have any effect on any Protected Health Information already used or disclosed before receipt of my written revocation notice.
- refusing to sign this form does not stop disclosure of my health information that is otherwise permitted by law without my specific authorization or permission.
- my authorized representative will be required to provide legal documents and may be required to provide proof of identity to prove their authority to sign on my behalf.
- the use of a copy of this Authorization (including electronic copy or email) for the disclosure of the information described above.
- this Authorization is invalid if modified.
- I am entitled to a copy of this Authorization after signing it.
I have read this Authorization and agree to the release, use and disclosure of my dental record or Protected Health Information (as described above).
Patient Name*
Patient Signature*

Clear
Date*

MonthDayYear
Date
Authorized representative name
Relationship
Authorized representative signature

Clear
Date

MonthDayYear
Date
Witness (optional)
Date

MonthDayYear
Date
A minor patient's signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment.
Signature of Minor (if applicable)

Clear
Date

MonthDayYear
Date
Should be Empty:

Authorization to Release Dental Record & Protected Health Information ("PHI") ("Authorization")