Patient Consent & Authorization for Release of Protected Health Information

Patient Authorization

Hereby authorize the release, use or disclosure of my health information as follows:

This authorization pertains to the following type of medical information about me:

To release the above-described information to Lisa A. Slaughter, DMD - kennebunkmedentist@gmail.com

I understand that, per my request, this authorization will permit the above-named parties to use or disclose the identified health information for purposes beyond treatment, payment, or healthcare operations as provided by the Health Insurance Portability and Accountability Act of 1996(HIPPA)

The revocation will be effective on the date it has been received and processed by the above-named recipient. I understand that the revocation does not apply to actions taken in reliance upon this authorization prior to the effective date of revocation. I also understand that I do not have to sign this authorization in order to receive treatment, payment, or to enroll or be eligible for benefits.

If I do not specify an expiration date or event, this authorization will expire ninety(90) days from the date on which I signed this authorization.

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the named recipient, and may no longer be protected by HIPAA's privacy rules after the authorized disclosure.

Patient or Personal Representative

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