Authorization to Disclose Protected Health Information
Release Information From:
SOUTH MISSISSIPPI SMILES
5717 E Thomas Rd Ste 100
Scottsdale, AZ 85251
Phone: 480-607-9999
Fax: 480-607-9989

By completing this Authorization, I authorize my Health Care Provider to disclose my protected health information.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the provider(s) of care.

I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that revocation will not apply to my insurance company when the law provides my insurer with the right to review or contest a claim. Unless otherwise revoked, this authorization will expire on the following date, event or condition:

I understand that any disclosure of healthcare information carries with it the potential for unauthorized and future re-disclosures, as allowed by HIPAA and other federal privacy rules. If I have questions about disclosures of my health information, I can contact my provider of care.

This facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the below information to the extent indicated and authorized herein.

*NOTE: You MUST upload a copy of your identification. This upload will be required at the end of this digital form and is required to complete the submission!
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