HIPAA FORM

HIPAA FORM
Patient Name
Patient Date of Birth

MonthDayYear
Date
I am opting to decline signing this form
AUTHORIZATION FORM TO USE OR DISCLOSURE OF PATIENT INFORMATION
I hereby authorize the use and disclosure of the patient information as described below.

Iunderstand that information disclosed pursuant to this authorization may be subject to

re-disclosure by the recipient and may no longer be protected by HIPAA Privacy regulations.

Specific description of the patient information to be used or disclosed:
Authorized User
FinancialAppointmentsTreatment
Authorized User
FinancialAppointmentsTreatment
Authorized User
FinancialAppointmentsTreatment
I understand that I may revoke this authorization at any time, and that my revocation is not effective unless it is in writing and received by the dental practice's Privacy Official at About Faces and Braces.

If I revoke this authorization, my revocation will not affect any actions taken by the dental practice before receiving my written revocation.

I understand that I may refuse to sign this authorization, and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan, or eligibility for benefits.

This authorization expires on the following date, or when the following event occurs when treatment is completed/terminated.
Signature of Patient/Parent/Guardian

Clear
Date

MonthDayYear
Date
Name of Personal Representative If Applicable
Relation to Patient
Should be Empty: