Spectra Health Dental ROI 2023

Authorization for Disclosure of Protected Dental Records

Patient Demographic Information
Patient Demographic Information

Complete the following fields using the patient information. Please note that only one patient may be listed per release of information form.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number
Please enter a valid phone number.
Patient Email
example@example.com
Other Name(s) Used by Patient
Maiden/former or other names used, if any

Your Rights with Respect to this Authorization and Signature Capture
I understand that if the person(s) and/or organization(s) listed about are not a health care provider, health plans or health care clearinghouses, who mustfollow the federal privacy standards, the health information disclosed as a result of the authorization may no longer be protected by the federal privacystandards and my health information may be redisclosed without 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

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

Clear
Today's Date*

MonthDayYear
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".
Should be Empty:

Authorization for Disclosure of Protected Dental Records

Patient Demographic Information

Third Party Information and Disclosure Details