HIPAA Right of Access Form for Family Member/Friend

Witness Name

direct my dental health care providers to disclose and release my protected health information described below to:

Name

Relationship

Name

Relationship

Health Information to be Disclosed upon request of the person named above: (check A or B):

A. Disclose my complete health record (including but not limited to diagnoses, prognosis, treatment, and billing, for all conditions)

B. Disclose my health record, as above, but do not disclose information related to the following:

Mental Health Records

Communicable Diseases (including HIV/AIDS,etc)

Alcohol/drug abuse history and treatment

Other

(If other, please specify):

This authorization shall be effective until (check one):

All past, present, and future periods

Date:

(If date, please specify):

unless I revoke it. (NOTE: You make revoke this authorization in writing at any time by notifying your healthcare providers, preferably in writing.)

Signature

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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