I authorize the professional office of my dentist named above to release health information identifying me
[including, if applicable, information about HIV infection or AIDS, information about substance abuse
treatment, and information about mental health services] under the following terms and conditions:
- Detailed description of the information to be released.
- To whom the information may be released [name(s) or class(es) of recipients].
- The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to
state "at the request of the individual" as the purpose, if desired by the individual).
- Expiration date or event relating to the individual or purpose for the release.
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you
if you choose not to sign this authorization.
If you sign this authorization, you can revoke it later. The only exception to your right to revoke it is if we
have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a
written or electronic note telling us that your authorization is revoked. Send this note to the office contact
person listed at the top of this form.
When your health information is disclosed as provided in this authorization, the recipient often has no legal
duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she
wishes. Sometimes, state or federal law changes this possibility.
[For marketing authorizations, include, as applicable: We will receive direct or indirect remuneration from
a third party for disclosing your identifiable health information in accordance with this authorization.]
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE
DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.
