HIPAA / Privacy Policy Consent Form

Release of Information Authorization Form

In compliance with federal and state law, the release of information for any person 18 years or older (including the information regarding a spouse or adult child), must first be authorized. Authorization includes the signature of the individual authorizing the release of their information. Information will not be available to anyone other than the covered patient (i.e. a member, a spouse, a partner, or any dependent age 18 or older) without first having this release of information authorization on file. However, parents do have a right to information on children under the age of 18 without the child's consent. The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time (HIPAA).

Information can and will be released and received via email, phone, fax or mail.

The following is an authorization allowing Elias Dental to release my information to whomever I have listed and designated. Elias Dental is authorized to make the release and disclosure of my information to include but not limited to the above information. This consent will continue indefinitely until revoked by me at any time in writing. I know that I can request the full Privacy Policy Document in person at Elias Dental or I can view it on their website.