AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

Patient’s name: _______________________ Date of birth: _____________

I request and authorize the release of health care information of the patient named above. Please send records to:

Bvdental227@gmail.com

Or

Gorgin Arasteh, DDS
Bayview Dental
1800 C Street #227
Bellingham, WA 98225
(360) 733-4940

I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. If I have been tested, diagnosed, or treated for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing, or treatment.

Signature of patient or patient’s authorized representative: ________________________

Date Signed: ____________

Relationship or status if signed by anyone other than the patient (parent, legal guardian, etc.): _______________________________

THIS AUTHORIZATION EXPIRES 90 DAYS AFTER THE SIGNED DATE ABOVE