Authorization For Use Or Disclosure Of Health Information printable pdf download

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

COMPLETE ALL SECTIONS, DATE AND SIGN

I, ____________________________________________, hereby voluntarily authorize the disclosure of protected health

(Enrollee Name)

information as described below:

The information is to be disclosed by:

And is to be provided to the following recipient:

NAME OF PERSON AUTHORIZED TO RECEIVE THE DISCLOSED INFORMATION

Delta Dental of California and Affiliates

STREET ADDRESS

P. O. Box 997330

CITY/STATE

Sacramento, CA 95899-7330

Protected Health Information (PHI) to be used or disclosed: (check appropriate box(es)

Information necessary to identify me including but not limited to, my name, address, telephone number, social security or other identification

number or other health information as listed below

Information relating to the dental services provided to me, including but not limited to date of service, type of service, treatment chart, x-rays,

dentists notes or other information as listed below

Information relating to the payment for the dental services including but not limited to Delta Dental’s payment, my payment or copayment and

total or aggregate payment or other information as listed below:

Information relating to my eligibility for benefits, including but not limited to enrollment, contribution or payment of the premium for the dental

benefit or other information listed below:

_______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

My protected health information will be used/disclosed for the following purpose(s):

______________________________________________________________________________________________________________________

I understand that I have the right to revoke this authorization. I understand that my request to revoke this

authorization must be in writing and can be mailed to: Delta Dental of California and Affiliates

Attn: Subscriber Services Department

P. O. Box 997330

Sacramento, CA 95899-7330

I understand that my protected health information may be subject to re-disclosure by the recipient and is no

longer protected by the privacy regulations issued pursuant to the Health Insurance Portability and

Accountability Act of 1996 (HIPAA).

This authorization is valid for one (1) year from the following date or event: ___________________________________

Please complete all applicable information.

POLICYHOLDER NAME

SOCIAL SECURITY NUMBER OR ENROLLEE ID

STREET ADDRESS

CITY/STATE

SIGNATURE OF PERSON AUTHORIZING RELEASE

DATE

AFFILIATE LIST ON PAGE 2

Authorization For Use Or Disclosure Of Health Information