Patient Name:

I hereby authorize Donna F. Helton, DDS, PC to release my patient health information as described below:

Date of Brith:
1) Name
1) Type of Information (Check one or both)
1) Relationship:
1) Method of Disclosure
2) Name
2) Type of Information (Check one or both)
2) Relationship:
2) Method of Disclosure
3) Name
3) Type of Information (Check one or both)
3) Relationship:
3) Method of Disclosure
4) Name
4) Type of Information (Check one or both)
4) Relationship:
4) Method of Disclosure

Protected health information (“PHI”) may include information/documents regarding dental/medical treatment of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointments and test results; account and billing information including, but not limited to, account balances, payments and payment arrangements, insurance claims status, and third-party financing.

I understand that the Health Insurance Portability and Accountability Act of 1996 and it’s implementing regulations (“HIPPA”) govern the terms of this Authorization. I understand that I have the right to revoke this Authorization at any time prior to the Practice’s compliance with the request set forth herein, provided that the revocation is in writing. I further understand that additional information relating to the exceptions, the right to revoke and description of how I may revoke this Authorization is set forth in Donna F. Helton DDS, PC Notice of Privacy Practices. I understand that any revocation must include my name, address, telephone number, date of this Authorization and my signature; and that I should send it to the attention of the “HIPAA Compliance Officer”.

I understand that I am not required to sign this Authorization and that Donna F. Helton, DDS, PC may not condition treatment on my execution of this Authorization.

I understand that the information used or disclose pursuant to this Authorization may be subject to re-disclosure by the recipient listed above and, in that case, will no longer be protected by HIPAA. This authorization expires when I am no longer a patient in this practice or have revoked this authorization.

Check One:

to Donna F. Helton, DDS, PC to leave information on my answering machine and on my phone by text and/or with my family members in regard to treatment plans, referrals, test result and/or billing and payment information. HIPAA guidelines allow for basic information regarding appointments (time, date, location) to be left on answering machine/phone text or with family members. HIPPA regulations authorize the release of PHI for the purpose of treatment, obtaining payment from third party payers, and the day-to-day health care operations of Donna F. Helton, DDS, PC. Other than those releases authorized by HIPAA, PHI will only be released to persons listed on this authorization. If you choose not to authorize any family members or friends for disclosure of PHI, Donna F. Helton, DDS, PC will not be able to release any information, including appointment or patient billing questions to anyone other than the patient.

Digital Signature of Patient or Personal Representative (ie: Guardian):
Date of Authorization:
Spam Verification:
Relationship of Personal Representative to Patient: