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HIPAA Right of Access Form for Family Member/Friend

direct my dental health care providers to disclose and release my protected health information described below to:
Health Information to be Disclosed upon request of the person named above: (check A or B):
This authorization shall be effective until (check one):
unless I revoke it. (NOTE: You make revoke this authorization in writing at any time by notifying your healthcare providers, preferably in writing.)


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.

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.