North Dallas Dental Health - Authorization to Disclose Health Information

Patient Name

First NameLast Name

Patient Date of Birth

Date

ID Number

By my signature below, I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.

Persons/organizations providing the information:

Persons/organizations receiving the information:

North Dallas Dental Health

Specific description of information (including dates):

Purpose of requested use or disclosure:

The patient or the patient's representative must read and initial the following statements:

1. I understand that I may revoke this authorization at any time by
notifying the providing organization in writing. I understand that the
revocation will not apply to information that has already been released
in response to this authorization and will not apply to my insurance
company when the law provides my insurer with the right to contest a
claim under my policy.
Initial Here*

2. I understand that my healthcare and the payment for my health care will not be affected if I do not sign this form.
Initial Here*

3. I understand that I may see and copy the information described on
this form and will receive a copy of this form after it is signed.
Initial Here*

4. If I have questions about disclosure of my health information, I can contact the office staff or the dentist.
Initial Here*

Signature of Patient or Legal Representative

Date

If Signed by Legal Representative, Relationship to Patient

Signature of Witness

This document will be retained by the providing organization for six years.