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
Which Zoo Crew location should we send this form to?
Patient First Name:
Patient Last Name:
Patient Date of Birth
Zoo Crew Dentist
(healthcare provider) to use and disclose the protected health information described below to (individual seeking the information)
Should we fax or mail your records?
Please provide the fax number to where the records should be released:
Address Line 2
2. Effective Period
This authorization for release of information covers the period of dental care
a specific date range
all past, present, and future periods.
3. Extent of Authorization
Mental Health - choose one:
I authorize the release of my child’s complete health record relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse. (Including radiographs, health history, treatment plan, chart notes and prescription records).
I authorize the release of my complete health record with the exception of the following information:
Mental health records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment
Other (please specify)
Other (please specify)
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.
5. This authorization shall be in force and effect until the following date or event, at which time this authorization expires:
**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:
Best number to reach you: