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Authorization for Release of Health Information

I understand and agree that:

  • This authorization is voluntary.

  • My Health information may contain information created by other persons or entities including health care providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease, and health care program information.

  • I will not be denied treatment if I do not sign this form.

  • I will not be denied payment for health (dental) care services if I do not sign this form.

  • I will not be denied enrollment or eligibility for health care benefits if I do not sign this form.

  • The recipient of my health information could disclose it to other parties who are not included in this authorization.

  • If parties are not health (dental) plans or health (dental) providers, then the information may no longer be protected by federal privacy regulations.

  • I may revoke this authorization at any time by calling LIBERTY Dental Plan at: 1.833.276.085, by writing LIBERTY Dental Plan, P.O. Box 15149, Tampa, FL, 33684 or sending a fax to: 1.888.700.1727.

  • The revocation will not influence my dental care.

 

Who May Receive and Disclose my information:

I authorize LIBERTY dental plan and its affiliates to disclose my individual identifiable health information to the following person(s) or organization(s):

Type of information to be disclosed. Please check one.
Purpose of Disclosure. Check one:

Please only click Submit once