HIPAA Authorization - Chris Siachos DMD

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

"*" indicates required fields

Name

Date of Birth

Email*

SSN#

Phone

Authorization

I authorize the Office of Dr. Christopher N. Siachos, to use of disclose my health information to the following persons:

Name:

My Rights

I understand that I have the right to revoke this authorization, in writing, at any time except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Today's Date*

Is the patient a minor?

Yes

Is the patient unable to sign?

Yes

If the patient is a minor, how many years of age?

If the patient is unable to sign, please explain why:

Comments

This field is for validation purposes and should be left unchanged.

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Authorization

My Rights

Book An Appointment

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Appointment Cancellation Policy

PATIENT RECORD TRANSFER REQUEST