Spectra Health Dental ROI

Authorization for Disclosure of Protected Health Information

Spectra Health Dental Clinic
Patient Name:

First NameLast Name
patient name print
Patient Date of Birth

MonthDayYear
dob print
Patient Address

Street Address, Unit/Apt

Street Address Line 2

CityState (Use Abbreviation)

Zip Code
Patient Phone Number
Patient Phone NumberFormat: (000) 000-0000.
Patient Email
Patient Email
Other Name(s) Used by Patient
Maiden/former or other names used, if any
Disclosure Details

Complete the following fields to indicate how you would like Spectra Health to interact with the designated third party, provide their contact information, and identify the information being authorized for disclosure. Only one third party can be designated per release.
This authorization allows Spectra Health to:
Name of Dental Clinic/Other Third Party
Name of the dental clinic you are authorizing to receive records from or send records to
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)

Other
ARCHIVED Expiration Date of This Release:

MonthDayYear
Authorization Expiration
Spectra Health acknowledges that the provision of the services is not contingent upon the client's decision concerning the release of this information. This consent is subject to revocation at anytime except to the extent that the program which is to make the disclosure has already taken action in reliance on it. A copy of this release is as effective as the original.

This authorization is valid for one year from the date signed if not previously revoked or otherwise specified below:
Would you like to specify an expiration date for this authorization?
Expiration Date of this Release:

MonthDayYear
expiration date print
Acknowledgement and Signature
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.
I understand that if the person and/or organization 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.
Is this form being completed by the patient or by a legal guardian of the patient?
Name of Legal Guardian/Authorized Representative
Relationship to Patient
If signed by someone other than the patient, state relationship and ability to do so
Patient or Legal Guardian Signature
self print
Today's Date

MonthDayYear
Today's Date
ARCHIVED Patient Name

First NameMiddle NameLast Name
sender email print
example@example.com
sender name print
Should be Empty:

Authorization for Disclosure of Protected Health Information

Disclosure Details

Authorization Expiration

Acknowledgement and Signature