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HIPAA Authorization
PATIENT AUTHORIZATION TO DISCLOSE OR OBTAIN PROTECTED HEALTH INFORMATION.
First Name
Last Name
Date Of Birth
I authorize Lancaster Dental Associates to discuss my dental treatment with:
Spouse name
Friend name
Family member(s) name
Other name
Description of information to be disclosed: I authorize the practice to disclose the following protected dental information about me to the entity, person, or person identified above:
Please explain
This authorization will expire one year from the date of your signature below, unless you specify an earlier termination. You must submit a new authorization after the expiration date to continue authorization.
As stated in our Notice of Privacy Practices, you have the right to terminate this authorization by submitting a written request to our Privacy Manger.
The practice places no condition to sign this authorization on the delivery of healthcare or treatment.
We have no control over the person (s) you have listed to receive your protected health information. Therefore, your protected health information, once disclosed under the authorization, will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.
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