Authorization Form to Release Medical Information to Family Member(s), Guardian, and Others

Patient’s name:

Date of Birth:

Many of our patients allow family members such as their spouse, parents, or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone with out the patient’s consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below.

I authorize medical providers and staff of Okemos Family Dentistry, P.C. to discuss and/or release my protected health information with/to:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

I understand that I have the right to revoke this authorization, in writinng, at any time. I understand that I have the right to inspect or copy the protected health information to be disclosed. I understand I can not revoke this authorization retroactively for information already released. I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient.

Patient Signature:

Date: