Authorization For Use Or Disclosure Of Protected Health Information printable pdf download

Authorization For Use Or Disclosure Of Protected Health Information

AUTHORIZATION FOR USE OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION

(Page 1 of 2)

1. Client’s name:

First Name

Middle Name

Last Name

2. Date of Birth: ____/___/___

3. SSN: ____-____-_____

4. Date authorization initiated: ___/___/___

5. Authorization initiated by:

Name (client or provider)

(If provider, please specify relationship to client)

6. Information to be Used or Disclosed:

My dental information relating to the following treatment or condition:

Most recent ___ years of record

My dental records for the following date(s):

Entire dental record

Include

Exclude: My health information related to drug and/or alcohol abuse

Include

Exclude: My health information related to HIV/AIDS

Other information to be used or disclose (describe information in detail):

7. Purpose of Use or Disclosure:

Treatment, Payment or Health Care Operations

Disclosure to Life Insurer for Coverage Purposes

Disclosure to Employer of results of pre-employment physical or lab tests

Marketing Purposes

To the Following Family Members:

Other (describe each purpose of the requested use and disclosure in detail):

8. Person(s) Authorized to Make the Disclosure:

9. Person(s) Authorized to Receive the Disclosure:

10. This Authorization will:

not expire,

expire on ___/___/___ or

upon the happening of the following event:

Authorization and Signature: I authorize the release of my confidential protected dental information, as described in my

directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law,

and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to

this authorization may be redisclosed by the recipient unless the recipient is covered by state laws that limit the use and/or

disclosure of my confidential protected dental information.

Signature of the Client:

Signature of Personal Representative:

Relationship to Client if Personal Representative:

Date of signature: ___/___/___

Authorization For Use Or Disclosure Of Protected Health Information

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