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Authorization to Release Health Information
Patient Information (First and Last Name):
Date Of Birth
Address
City
State
Zip Code
At my request, Bird Pediatric Dentistry/Braces by Bird may release the following information:
Name of Practice (Or Person Receiving Records)
Address
City
State
Zip Code
Email
**Please note that a release of records can typically take up to 72 hours for the receiving entity to obtain from our practice**
This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.
Patients 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. I can do this by written notification to Bird Pediatric Dentistry/Braces by Bird.
REvocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be proctected by federal or state law.
I may refuse to sign this authorization and that my treatment will not be conditioned on signing.
I understand released information may include a communicable disease diagnosis such as HIV.
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.
Patient/Legal Guardian Signature
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