rib-ads

| Home | Our Office |Our Services| Staff | Patient Education | Site Map |

RECORDS REQUEST AUTHORIZATION FORM

Records Request Authorization Form

I herby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.

Description of the specific information to be used or disclosed:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Person or entity requesting the information and authorized to make the requested use or disclosure:

 

_____________________________________________________________________________________________________________

 

Recipient of this information: ______________________________________________________________________________________

______________________________________________________________________________________________________________

 

This information is being requested for the following purpose(s):

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

 

This authorization shall remain in effect form the date signed below.

I understand that:

bullet

I may inspect or copy the protected health information to be used or disclosed

bullet

I may revoke this authorization in writing by contacting your office, attention Privacy Officer

bullet

Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPPA

bullet

I may refuse to sign this authorization and that you will not condition treatment or payment on me providing this authorization (expect to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research-related treatment

 

Patient Name: ______________________________________________            Signature: __________________________________

Date: ____________________________

Relationship to Patient

(if signed by personal respresntative of Patient): _________________________________  Date:__________________

 

 

Back  New Patient  Financial Information  Office Information    Home

ads

PLEASE NOTE: The information contained herein is intended for educational purposes only.  It is not intended and should not be construed as the delivery of dental/medical care and is not a substitute for personal hands on dental/medical attention, diagnosis or treatment.  Persons requiring diagnosis, treatment, or with specific questions are urged to contact your family dental/health care provider for appropriate care.
This site is privately and personally sponsored, funded and supported by Dr. Peterson.  We have no outside funding.
Confidentiality of data including your identity, is respected  by this Web site. We undertake to honor or exceed the legal requirements of medical/health information privacy that apply in Nebraska.

Copyright 1998-2017 Family Gentle Dental Care, all rights reserved.