Authorization To Release Dental Information printable pdf download

AUTHORIZATION TO RELEASE DENTAL INFORMATION

(The execution of this form does not authorize the release of information other than that specifically described below)

TO:_______________________________

RELEASE TO:___________________________________

__________________________________

_____________________________________________

__________________________________

_____________________________________________

Patient Name:_______________________________ DOB:_______________ SSN: _________________

I request and authorize the above‐named doctor or health care provider to release the information

specified below to the organization, agency or individual named on this request. I understand that the

information to be released includes the following information:

INFORMATION REQUESTED:

DATES COVERED:

___ Copy of complete dental chart

___ All treatment rendered in this office or by

this doctor

___ Copy of dental x‐rays

___ Limited to treatment dates for conditions

described below:

___ Other (e.g. models∙ describe)

_______________________________________

_________________________________________

_______________________________________

PURPOSE(S) OR NEED FOR WHICH INFORMATION IS TO BE USED:

___ Transfer of records

___ Second Opinion

___ Other ___________________________________________________________________________

AUTHORIZATION: I certify that this request has been made voluntarily and that the information given

above is accurate to the best of my knowledge. I understand that I may revoke this Authorization at any

time, except to the extent that action has already been taken to comply with it. Without my express

revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any

event: on__________ (date supplied by patient); or____ if revoked in writing by patient; or ___ 180

days from the date hereof; or ___ under the following conditions: ______________________________

_____________________________________________________________________________________

OTHER CONDITIONS: A copy of this Authorization or my signature thereon: _x_ may, ___ may not be

used with the same effectiveness as an original.

_______________________________________

PERSON AUTHORIZED TO SIGN FOR

PATIENT NAME (print)

PATIENT:

_______________________________________

PATIENT SIGNATURE

DATE ____________________________

State How Authorized_____________________

Authorization To Release Dental Information

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