Authorization To Release Health Information

Authorization To Release Health Information
Patient Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Request to the following Dental Office

Dentist Name

Street Address Line 2

CityState / Zip Code

Phone Number
At my request, the above listed dental office may release the following information to the office of Julie Ledford, DDS, PA Phone 828-389-8714

X-Rays or PhotosOffice Visit Notes
Please email to office@ledfordfamilydentistry.com
For email communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to move forward to allow email communications to occur.

I understand the above statement and still wish my records to be sent over Email
This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.

Patient Rights:

-I have the right to revoke this authorization at any time.

-I may inspect or copy the protected health information to be disclosed as described in this document.

-Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.

-Infromation used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or stater law.

-I understand released information may include a communicable disease diagnosis such as HIV.
Signature of patient or personal representative

Clear
Should be Empty: