Aspen Dental Health Information Release Form PDF Details

The Aspen Dental Health Information Release form is a document of notable importance, serving as a bridge for the transfer of medical records between Aspen Dental and external parties. This form lays the groundwork for patients or their authorized representatives to sanction the release of their dental treatment records. It delineates the scope of information to be shared, whether it encompasses all treatment details or is confined to data within specified treatment dates. This specification aids in tailoring the dissemination of information according to the patient's wishes, thereby ensuring a customized sharing approach. Furthermore, it underscores the patient's autonomy, highlighting the provision that allows for the retraction of consent at any given moment, should the patient decide to revoke the authorization. Such revocation necessitates a written notification to Aspen Dental, indicating a formal withdrawal process. The form encapsulates a comprehensive approach to the management of health information, ensuring that the patient's consent and preferences are front and center. With spaces for the inclusion of the recipient's details, alongside the necessity for the patient's (or patient representative's) signature and printed name, it ensures that all releases of information are both authorized and documented, reflecting a meticulous adherence to patients' rights and privacy concerns.

QuestionAnswer
Form NameAspen Dental Health Information Release Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesaspen dental new patient forms, aspen dental release form, informs aspen dental, aspen dental records form

Form Preview Example

PATIENT AUTHORIZATION FOR RELEASE

OF HEALTH RECORDS TO EXTERNAL PARTIES

I authorize the disclosure of information from my treatment records to:

Name of Recipient

Relationship to the Patient

I give authorization to disclose the following information:

All treatment information

Information specifically related to these treatment dates

Starting Date:

 

End Date:

I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no longer be used or released. I may revoke this authorization by notifying Aspen Dental in writing.

Signature of Patient (or Patient Representative)

 

Date

Printed Name of Patient (or Patient Representative)

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