Zoo Crew Dentist

HIPAA Privacy Authorization Form

**Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) **

1. Patient Info and Authorization

Should we fax, mail, or email your records? *

2. Effective Period

This authorization for release of information covers the period of dental care *

3. Extent of Authorization

Mental Health - choose one: *
Mental health records *

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. Expiration of authorization.

**If an expiration date is not provided this release form will automatically expire 30 days from the date listed below.** 

6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature of Parent or Legal Guardian: *