Personal Health Information Release Form (HIPAA Release Form)

Patient Name: _________________________________ Date of Birth: _________________ Release of Information I authorize the release of any and all protected health information (PHI), including the diagnosis, financial and dental records, examination rendered to me and claims information. This information may be released to:

☐ Spouse _______________________________________

☐ Parent(s)-if patient is 18 years of age, or older _____________________________________

☐ Child(ren) _____________________________________ If I have the option of insurance coverage through another individual (such as a spouse/partner or parent), I understand that I must list them on this form or Alpine Smiles will not be able to bill that policy on my behalf.

☐ Other ________________________________________

☐ This information is not to be released to anyone, including applicable insurance companies, making claim submission on my behalf no longer an option.

This Release of Information will remain in effect until terminated by me in writing. I agree that I am responsible for notifying Alpine Smiles of any changes regarding any applicable parties pertaining to my release of information form. The purpose of this request to release and/or disclose the PHI described above is for personal reasons and I understand that I have the right to revoke this Authorization, in writing, at any time by notifying Alpine Smiles. I understand that my healthcare provider cannot condition treatment on whether I sign this Authorization. However, if I refuse to sign this Authorization, I understand that I will be financially responsible for any treatment provided by Alpine Smiles. Messages Please contact me via: ☐ home # ________________ ☐ work # ________________ ☐ cell # ________________

☐ via email ______________________________ If unable to reach me directly: ☐ please leave a detailed message or email ☐ please leave a message or email asking me to return your call/email ☐ _________________________________________________ I understand that Alpine Smiles will try to accommodate my wishes regarding my contact information, but may have to contact me at the other numbers/email if unable to reach me at my requested number/location/email. Patient Signature: ___________________________________ Date:__________________ Reason for refusal to sign, if applicable:_____________________________________________________________________