HIPAA Authorization Please read and complete the form below. All fields are required. Name* First Last Email* Enter Email Confirm Email HIPAA Authorization*Please read and check each box below: Select All I agree to disclose, at my request, my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions. Forms of Disclosure Allowed - Electronic, paper and oral information and records. This authorization is valid for all past, present, and future periods. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request via email to firstname.lastname@example.org. The information disclosed per this authorization may be subject to redisclosure by the recipient and no longer protected by HIPAA. The provider may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I authorize Access Dental Care, and its staff, as detailed above, to share my Protected Health Information with The Giving Foundation, Inc., and its staff. Digital Signature* Please type your full name above to serve as your digital signature.PhoneThis field is for validation purposes and should be left unchanged.