Dental Authorization for Release of Information

Dental Authorization for Release of Information
Date

MonthDayYear
Date
Patient Full Name
Mailing Address
Phone #
Date of Birth

MonthDayYear
Date
Social Security Number
In case unable to locate patient with name or DOB
This information is to be used for the purpose of:

SelfInsuranceWorkers CompDisabilityAttorneyDentist or Other Healthcare Provider
This information is to be:

Mailed or Faxed to PatientMailed or Faxed to Dentist or Other Healthcare Provider as noted
Name/Facility/Agency
Mailing Address
Phone #
Fax #
Please enter a valid phone number.
Release the following with photo static copies regarding my treatment (required items must be checked):

Radiographic Images (CD of images)Treatment RecordPathology ReportsOther ImagesItemized Billing StatmentOther
OR select this option for Entire Dental Record

Entire Dental Record
Covering record time period from _______to_______I hereby release IHCWV Dental from all legal liability that may arise from further disclosure of said records (required - DO NOT date ahead)
Are you the patient?

YesNo
Signature of Patient

Clear
Date

MonthDayYear
Date
Signature of Legal Representative

Clear
Relationship to Patient
Date

MonthDayYear
Date
* My health record(s) will not be released or obtained unless permission is granted by my signature on this authorization.

* Only the record(s) checked above will be released for the stated reason(s).

* Although prohibited, it is possible that my PHI may be re-disclosed by the facility receiving my records, therefore, IHCWV Dental has no responsibility or liability as a result of the re-disclosure, and such information would no longer be protected by the HIPAA privacy rules.

* I am entitled to a copy of this completed authorization form.
This authorization is valid for one year from the date of signature, unless a specific time frame less than one year. Specified time for form validity:
ONLY enter date is NOT valid for one year
* I have the right to revoke this authorization at any time by sending a written request to: IHCWV Dental 190 Marie St. West Union, WV 26456

* By revoking this authorization: - My decision to revoke the authorization does not apply to any release of PHI that may have taken place prior to the revocation request. - My decision to revoke the authorization may result in my insurance company not being able to pay for the medical care and I may be liable for payment of the claims. - IHCWV Dental cannot require me to sign the authorization in order to receive treatment.
This authorization may be revoked at any time by the patient. The revoking of this authorization shall not cancel any prior action that has transpired. This authorization shall remain valid for the production of specified records until the date listed below OR a period of one year from the date of form completion. A new authorization will be required for any new visits to IHCWV Dental that occur after the date of this authorization. Authorizations cannot be given for future visits.
List date authorization shall remain valid IF less then one year.
NOTE: ADDITIONAL INFORMATION REGARDING HAND-CARRIED RECORDS OR MEDICAL INFORMATION INCLUDING

AIDS, SEXUALLY TRANSMITTED DISEASE, HIV RELATED DISEASES, DNA SCREENING, BLOOD ALCOHOL CONTENT, ALCOHOL/SUBSTANCE ABUSE, ADOPTION AND/OR PSYCHIATRIC RECORDS ARE REQUESTED ON THE REVERSE SIDE

IHCWV Dental 190 Marie Street West Union, WV 26456

Phone: 304-873-1401 ext. 201 Fax: 304-873-1542
Should be Empty: