ROI - Dental

Authorization to Release Dental Information

United Community Health Center - Maria Auxiladora, Inc.
United Community Health Center - Dental

1260 S Campbell Rd Bldg. 1

Green Valley, AZ 85614

Phone: 520-407-5617

Fax: 520-882-3255
Para ver en español, haga clic en el menú desplegable de idiomas en la esquina superior derecha y seleccione Español
I would like United Community Health Center (UCHC) to*

RELEASE information TO a Facility/Dental Office/Insurance Company/Attorney or individual/authorized personREQUEST records FROM a Facility/Dental Office
Where do you want records sent?*

Facility/Dental Office/Insurance Company/AttorneyIndividual/Authorized Person
Facility Name*
Individual/Authorized Person Name*
Type 'self' if requesting records for yourself
Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
Individual/Authorized Person Address*

Street Address

Street Address Line 2

CityState

Zip Code
Facility Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Individual/Authorized Person Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Facility Email
example@example.com
Patient Information:
Patient First & Last Name*
Patient Date of Birth*

MonthDayYear
Enter month/day/year
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient/Guardian Email
example@example.com
Reason for Request*

Transfer of CareInsurance Company UseDental Office/Facility UseAttorneyPersonal UseOther
Information to be disclosed:
Dates of service FROM*

MonthDayYear
Date
Dates of service TO*

MonthDayYear
Date
Information to be disclosed*

Dental X-RaysDental ReferralsDental Treatment PlanVisit Dental NotesOther
Delivery of Records*

MailEmail
United Community Health Center provides Integrated Medical, Dental, and Behavioral Health services. Records released may contain information related to all integrated services provided at our facilities unless noted below. I understand that my medical record may also include information on diagnosis/treatment related to psychiatric or psychological conditions, drug and/or alcohol abuse, acquired immune deficiency syndrome (AIDS), STI's, medications and/or HIV status, Psych Evaluations, Psychotherapy Notes, Drug/Substance Notes, Mental Health, Sexually Transmitted Infections, Diagnosis/Treatment of HIV or HIV related Illness.
If you want any records to be EXCLUDED from being released, please specify below:
By signing this authorization form, I understand that:

*I understand that I may revoke this authorization at any time, in writing, that the revocation will not apply to information that has already been released in response to this authorization, and that the authorization will automatically expire one year from the date of signature.

*I understand that there may be a retrieval and copy charge associated with this release.

*I understand that only information dated prior to the date of this authorization may be released.

*I do not authorize further release by the receiving requester to any third party, but I understand that once information is released pursuant to this authorization, the releasing facility or physician named above cannot prevent the re-disclosure of that information. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

*I understand that my participation is voluntary and that I am free to withdraw at any time, without giving a reason and without cost. I understand that I will be given a copy of this consent form if requested. I voluntarily agree to take part in the transfer of my records.
Who is signing this form?*

PatientAuthorized Person
Patient Typed Name*
Patient Signature*

Clear
Authorized Person Typed Name*
Authorized Person Signature*

Clear
Date*

MonthDayYear
Date
Relationship to Patient*
Reason Patient Unable to Sign*
Should be Empty:

Authorization to Release Dental Information