Consent To Release Health Information Form

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CONSENT TO RELEASE
HEALTH
INFORMATION
Please PRINT (except signatures) and provide complete answers (and addresses) in each section.
SECTION A: PATIENT GIVING AUTHORIZATION
Name: ______________________________________________ Axium #: _______________________________
Address: ___________________________________________________________________________________
Telephone: ______________________________ E-mail: ___________________________________________
Date of Birth ____________________________
Last 4 digits of Social Security #: ________________________
____
_____
Will the patient be returning to the College of Dentistry for further dental treatment?
Yes
No _____ Maybe
SECTION B: INFORMATION REQUESTED
Please be aware that the dental record may contain sensitive material. You have the option of us sending the copy of
your record directly to you.
Radiographs (X-rays)
Pathology Report
Progress Notes (Visit Information)
____________________________________________________________________________________________
Send to: ______________________________________________
Phone #: ____________________________
Select only one option below’
Pickup CD
$5
When:
Where:
Email
$10
Email Address __________________________________
Mail
$20
Mail Address___________________________________
______________________________________________
Fax (Progress notes only)
$10
Fax Number____________________________________
SECTION C: EXPIRATION and REVOCATION
This authorization will automatically expire one year from the date of signature, except as specified: _______________
Date
At that time, no express revocation shall be needed to terminate my consent, but understand that I may revoke this
consent at any time by sending a written notice to the Central Records, The University of Iowa College of Dentistry,
203 DSB North, Iowa City, Iowa 52242-1001. I understand that any release which was made prior to my revocation in
compliance with this authorization shall not constitute a breach of my rights to confidentiality. I understand that I may
review the disclosed information by contacting the Central Records, The University of Iowa College of Dentistry, 203
DSB North Iowa City, Iowa 52242-1001.
SECTION D: PATIENT’S SIGNATURE
I, the undersigned, hereby authorize The University of Iowa College of Dentistry to release dental information
concerning the above patient:
________________________________
Signature of Patient or Legal Guardian
Date
______________________________________________________________________________________
Address
City
State
ZIP
________________________________________________
Relationship, if NOT the Patient
UI College of Dentistry
Central Records
203 Dental Science North
319/335-7429
dent-crec@uiowa.edu
Iowa City, Iowa 52242-1001
Fax 319-335-7417
1/16/2015

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