AUTHORIZATION TO DISCLOSE INFO

Welcome to Artisan Dentistry!

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFO TO FAMILY MEMBERS & LEGAL REPRESENTATIVES
First Name*
Last Name*
Preferred Pronoun
Date of Birth*

MonthDayYear
Date
Referred By
Specialist/Friend/Online
I hereby authorize Artisan Dentistry/ Darcy Kasner, DDS to release my patient health information and financial arrangements including dental benefit information to the following people:
Name

First NameLast Name
Relationship
Ex: Mother, Husband, Child, etc.
Name

First NameLast Name
Relationship
Ex: Mother, Husband, Child, etc.
Name

First NameLast Name
Relationship
Ex: Mother, Husband, Child, etc.
Protected Health Information(PHI) may include information/documents regarding the dental/medical treatment of the patient including, but not limited to, diganosis, procedures, treatment plans, appointments, and account billing information.

I understand that the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and its implementing regulations govern the terms of this authorization. I understand that I have the right to revoke this authorization at any time in writing. I understand that any revocation must include my name, address, telephone number, date of this authorization, and my signature.

I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipients listed above and, in that case, will no longer be protected by HIPAA.

This authorization expires when I am no longer a patient in this practice or have revoked this authorization.
Do you agree to give Artisan Dentistry permission to leave information on your answering machine/device or with family members in regard to treatment plans, referrals, and/or billing and payment information? HIPAA guidelines allow for basic information regarding time and date of appointments to be left on an answering machine/device or with family members.*

I DO GRANT MY PERMISSIONI DO NOT GRANT MY PERMISSION
HIPAA regulations authorize release of PHI for the purpose of treatment, obtaining payments from third-party payers, and the day-to-day healthcare operations of Artisan Dentistry. Other than those releases authorized by HIPAA, PHI will only be released to persons listed above on this authorization. If you choose not to authorize any family members or friends for disclosure of PHI, Artisan Dentistry will not be able to release any information, including appointment or patient billing questions to anyone other than the patient.
Signature of Patient/Guardian or Personal Representative of Patient

Clear
Signer's Name*
Date of Authorization*

MonthDayYear
Should be Empty:

Welcome to Artisan Dentistry!