HIPAA Form

HIPAA Acknowledgement

Tao Dental Care - www.dentaltao.com, 10011 N. Foothill Blvd #109, Cupertino, CA 95014, yuan.tao.dmd@gmail.com, (408) 737-2988
I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to
federal or state law protecting its confidentiality,
By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signaturefor the HIPAA Disclosure Form.*
HIPAA AUTHORIZATION FOR RELEASE OF INFORMATION TO FAMILY AND/OR FRIENDS
Patient Name

LastFirst
MI
Prefered Name
Tao Dental Care is authorized to release protected health information about the above named patient to the following listed entities:
Entity Name:
Relationship:
Entity Name:
Relationship:
Check the box for any situation giving Tao Dental Care your authorization to supply information to your entity:

Text message and e-mai for appointment remindersE-MailGive information to spouseGive information to childRelease financial informationText messageLeave information on voice mailGive information to parent (patient is over 18 years of age)Give information to grandparentMedical information
Other information that you would like to give us authorization to release, please describe here:
Type a question
RIGHTS OF THE PATIENT: READ AND SIGN BELOW

I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION AT ANY TIME AND THAT I HAVE THE RIGHT TO INSPECT OR COPY THE PROTECTED
HEALTH INFORMATION TO BE DISCLOSED AS DESCRIBED IN THIS DOCUMENT BY SENDING A WRITTEN NOTIFICATION TO TAO DENTAL CARE. I UNDERSTAND
THAT A REVOCATION IS NOT EFFECTIVE IN CASES WHERE THE INFORMATIONHAS ALREADY BEEN DISCLOSED BUT WILL BE EFFECTIVE GOING FORWARD.
I UNDERSTAND THAT INFORMATION USED OR DISCLOSED AS A RESULT OF THIS AUTHORIZATION MAY BE SUBJECT TO REDISCLOSURE BY THE RECIPIENT
AND MAY NOLONGER BE PROTECTEDBY FEDERAL OR STATELAW.I UNDERSTAND THAT I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION AND
THAT MY TREATMENT WILL NOT BE CONDITIONED ON SIGNING THIS AUTHORIZATION.THIS AUTHORIZATION SHALL BE IN FORCE AND EFFECT UNTIL REVOKED
BY THE PATIENT OR REPRESENTATIVE SIGNING THE AUTHORIZATION.
Signature

Clear
Date

MonthDayYear
Date
If not parent or legal guardian: Description of personal representative's authority (attach necessary documentation)
Response Date

MonthDayYear
Date
Should be Empty:

HIPAA Acknowledgement

HIPAA AUTHORIZATION FOR RELEASE OF INFORMATION TO FAMILY AND/OR FRIENDS