Authorization for Release of Patient Information and Use of Records ("Authorization")
I authorize the release of information in the patient's record regarding the patient's treatment, and/or financial obligations related to the patient's treatment, to the parties listed below. I understand that once personal health and/or financial information is disclosed as per this Authorization, the Practice has no responsibility for any further release by the individual receiving the patient's information. I understand that I may refuse to sign this Authorization and that my refusal to sign this Authorization will neither affect non limit the patient's ability to obtain treatment or affect any payment, enrollment, or eligibility for benefits. I understand that I may revoke this Authorization by sending written notification to the Practice's Privacy Officer at the address set forth below; provided, however, that my notice to revoke this Authorization will not apply to actions taken in reliance on this Authorization prior to the date my written notice is received by the Practice's Privacy Officer.
Smile Doctors of Ohio Inc.
Attn: Privacy Officer
5400 LBJ Fwy, Suite 800 (Tower 1)
Dallas, TX 75240
This Authorization shall expire upon the earlier of: (i) the termination of the patient's treatment with the Practice; or (ii) my express written revocation of this Authorization with regard to a recipient. In each case, my historic authorization will remain effective as to protected health information that was disclosed prior to expiration/revocation of this Authorization.
I have read and understand the information contained within this Authorization and selected the applicable responses to indicate my agreement and to allow the use and disclosure of my/the patient's medical and/or financial record information as described above.