JORDAN VALLEY COMMUNITY HEALTH CENTER
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
PATIENT INFORMATION
Patient's Legal Name
*
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient MRN
Patient Email
example@example.com
AUTHORIZE THE RELEASE OF INFORMATION FROM
Dental Office Name
*
Address
City
State
Zip
AUTHORIZE THE RELEASE OF INFORMATION TO
Requestor
*
Name of Provider/Insurance/Employer/Self/Other
Requestor Address
Requestor City
Requestor State
Requestor Zip
Requestor Phone Number
Format: (000) 000-0000.
Requestor Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Requestor Email
INFORMATION TO BE DISCLOSED
Information to be disclosed
*
Dental Records
Dental Imaging
DATES OF INFORMATION TO BE DISCLOSED
Dates of Information to be disclosed
*
Previous 2 years of Dental Records
Other
FOR THE PURPOSE OF
For the purpose of:
*
Continuity of Care
Legal
Personal Records
Other
ACKNOWLEDGEMENT & SIGNATURE
Please indicate your acceptance by checking the following boxes: I understand that I may revoke this authorization inwriting at any time except to the extent that action has been taken in reliance upon this authorization (45 CFR §164.508(c)(2)(i)).
*
I understand
I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certaincircumstances such as for participation in research programs, or authorization of the release of testing results for pre-employment purposes (45 CFR § 164.508(c)(2)(ii)).
*
I understand
I understand that my records are confidential and cannot be disclosed without my written authorization except whenotherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to redisclosure bythe recipient and no longer protected.
*
I understand
I Understand that the specified information to be released may include, but is not limited to: history, diagnosis, and/ortreatment of drug or alcohol abuse, mental illness, or communicable disease, including Human Immunodeficiency Virus(HIV) and Acquired Immune Deficiency Syndrome (AIDS) (45 CFR § 164.508(c)(2)(iii)). This authorization will expireOne Hundred Eighty (180) days from the date of my signature unless I revoke the authorization prior to that time.
*
I understand
Signature
*
Date
*
/
Month
/
Day
Year
Date
Reason if patient is unable to sign
(Provide guardianship, executor of estate, death certificate, or power of attorney paperwork with request)
Submit
Should be Empty: