I hereby authorize , DDS to release the
information in the dental record of (patient’s name) to
Any and all information may be released including, but not limited to, mental health records protected by the
Lanterman-Petris-Short Act, drug and/or alcohol abuse records and/or HIV test results, if any, except as specifically
This authorization is effective now and will remain in effect until (date).
I understand that I may receive a copy of this authorization.
Use your mouse cursor or the tip of your finger to sign below
If not signed by the patient please indicate relationship:
NOTE: This authorization is intended to comply with applicable state laws. It is not intended as a “Consent” or
“Authorization” for the use and disclosure of Protected Health Information (PHI) under the federal Health Insurance
Portability and Accountability Act of 1996 (HIPAA) or its implementing regulations. The medical provider to
whom this authorization is directed should ensure that he or she is in compliance with applicable HIPAA
requirements before releasing the requested records.
CAUTION: If you intend to use the requested information for any purpose other than providing medical treatment,
45 CFR Section 164.502 requires that you make reasonable efforts to limit your request for PHI to the minimum
necessary to accomplish the intended purpose of the request.
To be valid, an authorization must be clearly separate from other language on a page and executed by a signature
which serves no purpose other than to execute the authorization. It can either be handwritten by the person who
signs it or in typeface no smaller than 8 point (this is 8 point).