Authorization to Release Dental Records

I, (Parent/Guardian Name), give permission to release copies of my child/children's dental records, for the purpose of patient care, from:

Dental Office Name

to:

Self or name of dentist, physician, agency, etc.

Street Address

City, State, Zip Code

Phone

Fax

Email

Information to be disclosed:

Exam and treatment notes
Current treatment plan
Copies of dental x-rays
Other

Purpose for disclosing information:

Consultation
Legal matter
Insurance
Other

I understand:

  1. I have the right to request a copy of this form after I sign it.
  2. I may revoke this authorization at any time by notifying Growing Grins Pediatric Dentistry in writing. However, it will not affect any actions taken before the revocation was received or actions taken in reliance thereon.
  3. The released information may no longer be protected, by federal privacy regulations, if the person or organization authorized to receive is not a health plan or health care provider.
  4. I will be given a copy of my dental records. The original record will remain the property of Growing Grins Pediatric Dentistry, and will be maintained by the office, in accordance with Indiana state laws.

Patients

Patient Name

Date of Birth

Patient Name

Date of Birth

Patient Name

Date of Birth

Patient Name

Date of Birth

Patient Name

Date of Birth

Printed Name of Parent/Guardian

Today's date

Signature of Parent/Guardian

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