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HIPAA Release Authorization

 

 

www.TheFreeDentist.com

 

AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION

 

This authorization complies with the HIPAA Privacy Rule.

 

By checking on the “Agree” box for the “HIPAA Authorization for Release” during the www.TheFreeDentist.com

sign up process, you have read, reviewed, understood, and agreed to the terms below.  This will also confirm you e-signature.

 

This section does not apply. You must be 18 or older to sign up for www.TheFreeDentist.com

 

A.  Identification

This document authorizes the use and/or disclosure of confidential protected health information about the following person:

 

Client/Patient Name: 

First and Last Name identified by Patient signing up on www.TheFreeDentist.com

 

 

 

______________________________________________________________________

 

Address:

Address identified by Patient signing up on www.TheFreeDentist.com

 

 

 

______________________________________________________________________

                                                                                                                                                           

Client/Patient Date of Birth:

Month/Day/Year identified by Patient signing up on www.TheFreeDentist.com

 

 

 

_______________________________________________                                                 

Daytime Phone Number: 

Phone Number identified by Patient signing up on www.TheFreeDentist.com

 

 

 

 __________________________________________

 

Client/Patient Social Security Number: 

Social Security has not and WILL not be requested by www.TheFreeDentist.com  - If this information is requested by the Dentist, you will release at your own will.

__________________________________

B.  Directions for Release

This authorization applies in accordance with my directions as checked below.  I authorize the following identified below to be released and/or use my protected health information to Care Guide Advocacy.  I understand that the information to be disclosed and/or used may include enrollment information, eligibility information, premium (payment) information, claims records, claims status patient search, and medical/clinical management records, according to my directions. 

 

CHECK ALL THAT APPLY:

I authorize the obtaining of information from:

X     Employee Benefits Division

___ My Health Plan (Name):_______________________________________________

___ My Physician/Provider (Name): _________________________________________

___ My Legal/Personal Representative (Name or describe): ______________________

______________________________________________________________________

X Other (Name or describe): www.TheFreeDentist.com users including website administration. Potential Dentists, contractors, and any medical provider who can potential provide medical services for the Patients who have signed up on www.thefreedentist.com

_____________________________________________

 

CHECK ALL THAT APPLY:

I authorize the disclosure and/or use of the following information:

X (a) any information related to a specific claim (specify date of service or type of treatment):_____________________________________________________________

X (b) my entire medical record

X (c) my enrollment, eligibility and premium payment records

X (d) Other (describe information in detail): All information requested and provided by the Patient when signing up on www.TheFreeDentist.com. Including but not limited to:

 

CHECK ALL THAT APPLY:

I understand and authorize the disclosure and/or use of the following information will be used for:

X (a) Further Medical Care.

X (b) Research

X (c) Sold, used, and/or distributed at will by www.TheFreeDentist.com

____________________________________________________________________

 

CHECK ALL THAT APPLY:

I authorize the disclosure and/or use for the following reason(s):

X (a) for review and appeal of a claim denial

X (b) for assistance with my plan coverages and benefits

X (c) for assistance with my dependent’s plan coverages and benefits

X (d) for my own purposes

X (e) Other(describe purposes in detail):  Allowing users of www.TheFreeDentist.com to inquire about potential Patients with specific conditions in their search inquiry.

 

Right to Revoke:

I understand that I may revoke this Authorization at any time except to the extent that action has already been taken in reliance upon it.

If I do not revoke it, this Authorization shall terminate on upon my written revocation actually received by the covered entity.  To revoke the Authorization, I understand I must contact the following in writing:  TheFreeDentist www.TheFreeDentist.com and send an email to CancelHIPAA@thefreedentist.com with the following information:

 

-       First and Last Name

-       Address, City, State, Zip

-       Phone Number

-       Confirm you would like www.TheFreeDentist.com that you would like us to CANCEL and REVOKE the HIPAA Confidentiality Agreement.  


YOU ARE ALSO AGREEING TO THE FOLLOWING VIA ELECTRONIC SIGNATURE:

Authorization and Signature:  I authorize the release of my confidential protected health information, as described in my directions in Section B.  I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions.  The information that is used and/or disclosed pursuant to this authorization may be redisclosed by the recipient except in any situation where any laws limit the use and/or disclosure of my confidential protected health information.  My treatment, payment, enrollment and eligibility are not conditioned on signing this authorization but the information authorized may be necessary for claim review and appeal purposes.

 

I, First and Last Name of Patient signing up on www.TheFreeDentist.com, have read the contents of this Authorization, and I confirm that the contents are consistent with my directions.  I understand that by signing this form, I am authorizing the use and/or disclosure of my confidential protected health information.

 

I understand that www.TheFreeDentist.com will not condition treatment or eligibility for care on my providing this authorization except if such care is: (1) research related or (2) provided solely for the purpose of creating Protected Health Information for disclosure to a third party.

 

I understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164] , and the Privacy Act of 1974 [5 USC 552a].

 

By checking on the “Agree” box for the “HIPAA Authorization for Release” during the www.thefreedentist.com sign up process, you have read, reviewed, understood, and agreed to the terms below.  This will also confirm your e-signature.

 

The date of this form will be based on the date you have signed up on www.TheFreeDentist.com.

 

 

HIPAA Release Authorization

 

 

www.TheFreeDentist.com

 

AUTHORIZATION FOR RELEASE OF HEALTH-RELATED INFORMATION

 

This authorization complies with the HIPAA Privacy Rule.

 

By checking on the “Agree” box for the “HIPAA Authorization for Release” during the www.TheFreeDentist.com

sign up process, you have read, reviewed, understood, and agreed to the terms below.  This will also confirm you e-signature.

 

This section does not apply. You must be 18 or older to sign up for www.TheFreeDentist.com

 

A.  Identification

This document authorizes the use and/or disclosure of confidential protected health information about the following person:

 

Client/Patient Name: 

First and Last Name identified by Patient signing up on www.TheFreeDentist.com

 

 

 

______________________________________________________________________

 

Address:

Address identified by Patient signing up on www.TheFreeDentist.com

 

 

 

______________________________________________________________________

                                                                                                                                                           

Client/Patient Date of Birth:

Month/Day/Year identified by Patient signing up on www.TheFreeDentist.com

 

 

 

_______________________________________________                                                 

Daytime Phone Number: 

Phone Number identified by Patient signing up on www.TheFreeDentist.com

 

 

 

 __________________________________________

 

Client/Patient Social Security Number: 

Social Security has not and WILL not be requested by www.TheFreeDentist.com  - If this information is requested by the Dentist, you will release at your own will.

__________________________________

B.  Directions for Release

This authorization applies in accordance with my directions as checked below.  I authorize the following identified below to be released and/or use my protected health information to Care Guide Advocacy.  I understand that the information to be disclosed and/or used may include enrollment information, eligibility information, premium (payment) information, claims records, claims status patient search, and medical/clinical management records, according to my directions. 

 

CHECK ALL THAT APPLY:

I authorize the obtaining of information from:

X     Employee Benefits Division

___ My Health Plan (Name):_______________________________________________

___ My Physician/Provider (Name): _________________________________________

___ My Legal/Personal Representative (Name or describe): ______________________

______________________________________________________________________

X Other (Name or describe): www.TheFreeDentist.com users including website administration. Potential Dentists, contractors, and any medical provider who can potential provide medical services for the Patients who have signed up on www.thefreedentist.com

_____________________________________________

 

CHECK ALL THAT APPLY:

I authorize the disclosure and/or use of the following information:

X (a) any information related to a specific claim (specify date of service or type of treatment):_____________________________________________________________

X (b) my entire medical record

X (c) my enrollment, eligibility and premium payment records

X (d) Other (describe information in detail): All information requested and provided by the Patient when signing up on www.TheFreeDentist.com. Including but not limited to:

 

CHECK ALL THAT APPLY:

I understand and authorize the disclosure and/or use of the following information will be used for:

X (a) Further Medical Care.

X (b) Research

X (c) Sold, used, and/or distributed at will by www.TheFreeDentist.com

____________________________________________________________________

 

CHECK ALL THAT APPLY:

I authorize the disclosure and/or use for the following reason(s):

X (a) for review and appeal of a claim denial

X (b) for assistance with my plan coverages and benefits

X (c) for assistance with my dependent’s plan coverages and benefits

X (d) for my own purposes

X (e) Other(describe purposes in detail):  Allowing users of www.TheFreeDentist.com to inquire about potential Patients with specific conditions in their search inquiry.

 

Right to Revoke:

I understand that I may revoke this Authorization at any time except to the extent that action has already been taken in reliance upon it.

If I do not revoke it, this Authorization shall terminate on upon my written revocation actually received by the covered entity.  To revoke the Authorization, I understand I must contact the following in writing:  TheFreeDentist www.TheFreeDentist.com and send an email to CancelHIPAA@thefreedentist.com with the following information:

 

-       First and Last Name

-       Address, City, State, Zip

-       Phone Number

-       Confirm you would like www.TheFreeDentist.com that you would like us to CANCEL and REVOKE the HIPAA Confidentiality Agreement.  


YOU ARE ALSO AGREEING TO THE FOLLOWING VIA ELECTRONIC SIGNATURE:

Authorization and Signature:  I authorize the release of my confidential protected health information, as described in my directions in Section B.  I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions.  The information that is used and/or disclosed pursuant to this authorization may be redisclosed by the recipient except in any situation where any laws limit the use and/or disclosure of my confidential protected health information.  My treatment, payment, enrollment and eligibility are not conditioned on signing this authorization but the information authorized may be necessary for claim review and appeal purposes.

 

I, First and Last Name of Patient signing up on www.TheFreeDentist.com, have read the contents of this Authorization, and I confirm that the contents are consistent with my directions.  I understand that by signing this form, I am authorizing the use and/or disclosure of my confidential protected health information.

 

I understand that www.TheFreeDentist.com will not condition treatment or eligibility for care on my providing this authorization except if such care is: (1) research related or (2) provided solely for the purpose of creating Protected Health Information for disclosure to a third party.

 

I understand that information disclosed by this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be subject to redisclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164] , and the Privacy Act of 1974 [5 USC 552a].

 

By checking on the “Agree” box for the “HIPAA Authorization for Release” during the www.thefreedentist.com sign up process, you have read, reviewed, understood, and agreed to the terms below.  This will also confirm your e-signature.

 

The date of this form will be based on the date you have signed up on www.TheFreeDentist.com.