Authorization to Release Dental Records
PATIENT INFORMATION:
Full Name
Street Address
City
State
Zip Code
Date of Birth
Phone
SEND RECORDS TO:
Self or Name of Dentist, Physician, Agency, Etc.
Street Address
City
State
Zip Code
Phone
Fax
Send via e-mail:
INFORMATION TO BE DISCLOSED:
Exam & Treatment Notes
Date:
Radiographs (X-rays)
Date:
Treatment Plan
Date:
Other (specify):
PURPOSE(S) FOR DISCLOSING INFORMATION:
Consultation
Continuation of Care
Attorney Inquiry/Legal Matter
Other (specify):
I understand all information I hereby authorize to be obtained will be held strictly confidential and cannot be released without my written consent. I understand this authorization will remain in effect until revoked by me in writing.
I understand unless otherwise limited by state or federal regulations, and except to the extent action has been taken which was based on my consent, I may withdraw this consent at any time by submitting my request in writing.
Patient/Guardian Name:
Patient/Guardian Signature
Date:
Witness Name:
Signature of Witness
Date:
AUTHORIZATIONS SIGNED BY A LEGAL REPRESENTATIVE MUST INCLUDE A COPY OF THE GUARDIANSHIP PAPERS OR A POWER OF ATTORNEY.
These can be attached here or faxed to (219) 286-6149.