Alumni Dental Authorization to Release Health Care Information

Alumni Dental Authorization to Release Health Care Information
Patient's Name*
Date of Birth*

MonthDayYear
Date
SSN*
Doctor's Name*
Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I request and authorize the above listed doctor to release health care information of the patient named above to: Alumni Dental Center, Drs. Kopczyk, Vieth & Majors DMD, 2335 Sterlington Road Suite 200, Lexington, KY 40517.
This request and authorization applies to health care information relating to the following treatment, condition, or dates of treatment:
Or All Health Care Information
Or Other:
THIS AUTHORIZATION EXPIRES ON Date OR 30 DAYS AFTER THE DATE IT IS SIGNED, OR WHEN THE FOLLOWING EVENT OCCURS: event description
I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know that canceling this authorization would not prohibit any release of information by the doctor or practice in reliance on my original authorization.

There are two ways to cancel this agreement. I can:
- Sign and date a form available from the doctor or practice called "Revocation of Authorization for Use and Disclosure of Health Care Information" or
- Write a letter to the doctor or practice. If I write a letter, it must state that I want to cancel my authorization to disclose my health care information. My letter must include the name or other specific identification of the person(s) that I no longer want to receive information. I (or my authorized representative) must sign and date the letter.
Once my doctor gives out the information that I want released, I know that my doctor has no control over the information. The individual or organization that I authorize to receive the information might re-disclose it. Federal or state privacy laws may no longer protect the information.
Sign Electronically-Binding Signature Here*

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Date*

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Date
Relationship or status if signed by the parent, legal guardian, personal representative, etc.
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