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.