AUTHORIZATION TO RELEASE MEDICAL/ DENTAL CONFIDENTIAL INFORMATION

I, Date of Birth: authorize to:

The following information pertaining to myself:

For the purpose of:

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Privacy Officer. I understand that revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition. Expiration Date: . If I fail to specify an authorization date, event or condition, this authorization will expire in 180 days.

I understand that authorizing the disclosure of this dental/ health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to ensure treatment. I understand that I may inspect or request a copy of the information used or disclosed as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re disclosure and the information may not be protected by federal confidentiality rules.