Authorization for Release of Protected Health Information

Patient Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

I hereby authorize Drake Family Dental, LLC to release the above-described information to (list individuals):
This information may be disclosed to, and used by, the following person(s) or organization(s) to assist me.

Name

First Last

Relationship

Name

First Last

Relationship

I understand that, per my request, this authorization will permit the above-named parties to use or disclose the identified health information for purposes beyond treatment, payment, or healthcare operations as provided by the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

I understand that I may revoke this authorization at any time by providing written notification to: Drake Family Dental, LLC

The revocation will be effective on the date it has been received and processed by the above named recipient. I understand that the revocation does not apply to actions taken in reliance upon this authorization prior to the effective date of revocation. I also understand that I do not have to sign this authorization in order to receive treatment or payment.

Unless I request in writing otherwise, I understand that this authorization will expire on:

Expiration Date

If I do not specify an expiration date or event, this authorization will expire 24 months from the date on which I signed this authorization. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the named recipient, and may no longer be protected by HIPPA's privacy rules after the authorized disclosure.

Individual or Legal Representative Signature

Signature(Required)

Date(Required)

Name(Required)

First Last

Relationship to Patient