Patient Authorization Form

Limited Patient Authorization for Disclosure of Protected Health Information

Please correct the errors described below.

Please print all information. Form must be signed and dated.

I acknowledge that I have received/been offered the Notice of Privacy Practices issued by Todays Dental Comfort which was effective 2/14/2018. I allow Today’s Dental Comfort to disclose or provide protected health information about me to the individual(s) listed below.

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o This authorization will remain in effect until

  • You specify a termination or change of contacts
  • Patient becomes 18 years of age if minor at time of form filled out.

o You have the right to terminate this authorization at any time by submitting a written request to our office. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.

o The practice places no condition to sign this authorization on the delivery of healthcare or treatment.

o We have no control over the person (s) you have listed to receive our protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

You have the right to receive a copy of signed authorizations upon request.

Person to contact in case of emergency:

Primary Insurance Information:

Secondary Insurance Information:

Authorization:

I hereby authorize payment directly to Today’s Dental Comfort of the group insurance benefits otherwise payable to me I Understand I am responsible for all costs of dental treatment not otherwise paid by my insurance carrier. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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