HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act -45 CFR Parts 160 and 164)

  1. I hereby authorize Dr. McNamara to use and/or disclose the protected health information described below to

    [Name of Individual]
  2. Authorization for Release of Information. Covering the period of health care from
    to
    OR
    all past, present and future periods:
    1. I hereby authorize the release of my complete health record (including records relating to mental health care, communicable diseases, H1V or AIDS, and treatment of alcohol/drug abuse).
      OR
    2. I hereby authorize the release of my complete health record with the exception of the following information:
      Mental health records
      Communicable diseases (including HIV and AIDS)
      Alcohol/drug abuse treatment
      Other (please specify):

  3. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
  4. This authorization shall be in force and effect until , at which time this authorization expires. [Date or Event]
  5. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
  6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
  7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature of Patient or Personal Representative

Date


Relationship to Patient



PROGRESSIVE PERIODONTICS & DENTAL IMPLANTS S.C. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of PROGRESSIVE PERIODONTICS AND DENTAL IMPLANTS Notice of Privacy Practices. This Notice describes how Progressive Periodontics and Dental Implants may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.


Signature of Patient or Personal Representative

Date


Relationship to Patient

Please select the office you wish to be seen at:

West Bend 1305 Chestnut Street, West Bend, WI 53095

Greenfield 8405 W. Forest Home Avenue, Greenfield, WI 53228