AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I authorize Gallavin Dentistry to Use or Disclose the following information from my medical record:

My Entire Medical Record

My Medical Records dated from

Protected Health Information Relating to

Other (please explain):

I authorize Gallavin Dentistry to Disclose my health information to:

Address

City

State

Zip

Telephone

Fax

Disclosure of my health information is being made for the purpose(s) of:

At the request of the Individual or Individual's personal representative Permission to return to work, sick note, or medical excuse

Insurance enrollment or coverage

Life insurance, automobile insurance or disability insurance claim

Employment purpose (please specify):

Other (please specify):

Authorization for Disclosure of my health information will expire in 60 days or on:

Please specify date:

Please specify event, if not a specific date:

Adjudication of claim

I understand that if the person or entity to whom Gallavin Dentistry is disclosing my information is not a doctor, health care provider or health plan, the information may not be protected by HIPAA, and that person may Use or Disclose that information to other non-covered entities. I understand that the information in my health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand that my refusal to sign this Authorization will not affect my ability to obtain treatment from Gallavin Dentistry. It may affect my ability to return to work or receive an employee or insurance benefit.
I understand I have the right to inspect or copy information Disclosed by this Authorization. I understand I may revoke (cancel) this Authorization at any time. Revocation must be in writing. Gallavin Dentistry cannot be held responsible for having Disclosed information in reliance on this Authorization before receiving a written revocation.
. I understand that Gallavin Dentistry and its Workforce are released from legal responsibility or liability for disclosing protected health information authorized by my signature below.
I acknowledge I had an opportunity to ask questions before I signed and that I may receive a copy of the signed Authorization.

Print Name of Individual or Individual's Representative

Signature

Date

Patient's Date of Birth

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue