SDG Release form

Dental Records & Protected Health Information ("PHI") Release Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

City, State, Zip
Phone Number*
Please enter a valid phone number.
I authorize Shemen Dental Group, LLP to release a copy of my dental records 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:*

Self (patient listed above)Other
Delivery Options:*

MailEncrypted EmailFaxPick Up
Email*
example@example.com
Reason for Records Request*
Only information from the past seven (7) years will be disclosed unless a specific date range is provided below.
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Information to be disclosed: *
I do not want the following information to be disclosed:
EXPIRATION: This Authorization is good for one year from the date it is submitted by the patient or responsible party.

By signing, I agree and acknowledge that:
- I have the right to revoke this authorization at any time, provided I do so in writing to Shemen Dental Group, LLP. 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
- This authorization remains effective until Shemen Dental Group, LLP is in actual receipt of a signed revocation, or until the records retention period required under federal and state law has expired and the records have been destroyed
- I am entitled to a copy of this signed authorization
- I may inspect a copy of my protected health information to be used or disclosed under this authorization
- 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 Shemen Dental Group
- Shemen Dental Group, LLP has not conditioned the provision of services to, or treatment of me, upon receipt of this signed authorization
- The information released, if re-disclosed by the recipient, is no longer protected by Shemen Dental Group
- Refusing to sign this form does not stop the disclosure of my health information that is otherwise permitted by law without my specific authorization or permission
- A copy of this signed, dated authorization shall be as effective as the original
Patient Name*

First NameLast Name
Who is the individual signing?*

PatientSomeone Else
Signature*

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Today's Date*

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

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Today's Date

MonthDayYear
Date
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Dental Records & Protected Health Information ("PHI") Release Form