AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations, and that it may be re-disclosed by the recipient.

Patient Name: ___________________________________________________

Organization Providing the Information: Reynoldsburg Family Dental

Organization(s) or Person(s) Receiving the Information:__________________
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Specific Description of Information Disclosed: ___________________________
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Purpose of Disclosure: ______________________________________________
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If this Authorization is for marketing purposes, remuneration is/is not involved (Provider circle one)

Date of Services: ____/____ /____ (DD/MM/YR)

You must read and initial the following statements:

1. I understand this Authorization will expire on ____ /____ /____ (DD/MM/YR) or on the following event ___________________________. Initials: __________

2. I understand that I may revoke this Authorization at any time by notifying Reynoldsburg Family Dental in writing, but if I do, it will not have any effect on any actions Reynoldsburg Family Dental took before they received the revocation. Initials: __________

 

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Signature of Patient or Representative
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Relationship to Patient	Date