Spectra Health Dental ROI

Patient Name

First NameLast Name

Patient Date of Birth

Patient Address

Street Address, Unit/Apt

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Phone Number

Format: (000) 000-0000.

Patient Email

Other Name(s) Used by Patient

Maiden/former or other names used, if any

This authorization allows Spectra Health to:

Name of Dental Clinic/Other Third Party

Address of Dental Clinic/Other Third Party

Street Address, Unit/Apt

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Contact for Dental Clinic or Other Third Party

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Information to be disclosed (check all that apply)

I understand that if the person(s) and/or organization(s) listed above are not a health care provider, health plan, or health care clearinghouse - all of which must follow federal privacy standards - the health information disclosed as a result of this authorization may no longer be protected by federal privacy standards and my health information could be re-disclosed without again obtaining my authorization.

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

Right to Inspect or Copy the Health Information to Be Used or Disclosed - I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting Spectra Health Clinical Records Department at (701) 757-2810.

Right to Receive Copy of This Authorization - I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form.

Right to Refuse to Sign This Authorization - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization.

Right to Withdraw This Authorization - I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact: Spectra Health Clinical Records Department at (701) 757-2810. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the person(s) and or organization(s) listed above have already made in reference to this authorization.

Expiration Date

If no expiration date is specified, this form will be valid for one year from the signature date

Relationship to Patient

If signed by someone other than the patient, state relationship and ability to do so (e.g., parent, legal guardian, power of attorney, etc.), otherwise, state "self".

Signature

Today's Date

Authorization for Disclosure of Protected Health Information

Patient Information

Disclosure Details