Authorization to Release Dental Records

Authorization to Release Dental Records

PATIENT INFORMATION:

Patient First Name:

Last 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

Archive Patient of Record: No Yes

Attorney Inquiry/Legal Matter

Other (specify):

I understand that all information I hereby authorize to be obtained will be held strictly confidential and cannot be released without my written consent. I understand that this authorization will remain in effect until revoked by me in writing.

I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by submitting my request in writing.

Full Name (Patient/Guardian):

Signature (Patient/Guardian)

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 (317) 596-9659. .