Bruce R. Brown DDS

14 Roosevelt Avenue

Port Jefferson Station, NY 11776

PATIENT AUTHORIZATION FOR PRACTICE TO RELEASE

PROTECTED HEALTH INFORMATION TO THIRD PARTIES

FOR PURPOSES SPECIFIED BY THE PRACTICE

By signing this authorization, I authorize Bruce R. Brown DDS to use and/or disclose certain protected health information (PHI) about me to or for the party or parties listed below. This authorization permits Dr. Brown to use or disclose any necessary personal health information to entities or agencies (hospitals, labs, physicians, insurance companies, et al.), the following individually identifiable health information: consults, office visits, test results, billing information and anything relevant to patient care and/or claims processing.

When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPPA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that Dr. Brown has acted in reliance upon this authorization. My written revocation must be submitted to Dr. Brown at 14 Roosevelt Avenue, Port Jefferson Station, NY 11776.

I have the right to review the Notice of Privacy Practices (displayed in waiting room) prior to signing this consent, and a copy of the Notice will be provided upon request. A copy of this authorization will also be provided to you upon request.

Signed by: __________________________________          ________________________

                        Signature of Patient/Guardian                        Relationship to Patient

                 __________________________________            ________________________

                        Patient Name                                                  Date