Choice Dental

AUTHORISATION FOR RELEASE OF PROTECTED HEALTH INFORMATION - DENTAL RECORD

Patient Last Name:(Required)

Patient First Name:(Required)

Date of Birth(Required)

Address(Required)

Street Address ZIP / Postal Code

E-mail:(Required)

Mobile:(Required)

PATIENT AUTHORISATION

I, do hereby authorize

Old Dentist Name(Required)

to release a copy of my dental records, x-rays and those of my dependents (if applicable), and release them to Choice Dental Browns Plains - send records to enquiries@choice-dental.com.au

Dependent Name

Date of Birth

Dependent Name

Date of Birth

Dependent Name

Date of Birth

(PLEASE NOTE): If records are released directly to you, a $30 administration fee is required by Choice Dental. There is no fee for records released directly to other healthcare providers).

PURPOSE OF INFORMATION RELEASE(Required)

Other (specify):

PATIENT PRIVACY/Agreement

I understand it is recommended that records be released directly to a dentist/health care provider. This will ensure the protection of health information being only released via a secure and traceable method.
I understand that protected health information disclosed pursuant to this authorisation may be re-disclosed by the recipient(s) to other individuals or organisations that are not subject to privacy protection laws. I also hereby release Choice Dental from all legal responsibilities and liabilities that may arise from the release of such protected health information.
I understand that the release of these confidential records is at the discretion of the treating dentist and the original records remain the property of the dentist who created them.
I agree to provide two forms of ID. One must be a government photo ID

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE:

Name:(Required)

Date(Required)

Signature of patient /personal representative:(Required)

If signed by anyone other than the patient, state the relationship to patient and/or reason and legal authority for signing. (Proof required) Patient is:

Incompetent

Disabled

Deceased Legal Authority

Parent Legal Guardian

Next of Kin of Deceased