Sample Authorization To Release Dental Information

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The Center for Pediatric Dental Care
DEVELOPING POSITIVE ATTITUDES FOR HEALTHY SMILES
SM
AUTHORIZATION TO RELEASE DENTAL INFORMATION
The execution of this form does not authorize the release of information other than specifically described below.
Date:
Patient Name(s):
Release to:
Address:
Date of Birth(s):
INFORMATION REQUESTED
_________ Summary of dental chart
_________ Copy of most recent x-rays
_________ E-mail of most recent x-rays
_________ Other (e.g. models-describe)
PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED
_________ Transfer of records
_________ Second opinion
_________ Other_______________________________________________________
AUTHORIZATION: I certify that this request has been made, and that the information given above is accurate to
the best of my knowledge. I understand that I may revoke this Authorization at anytime, except to the extent that
action has already been taken to comply with authorization. Without my express revocation, this consent will
automatically expire upon satisfaction of the need for disclosure.
Authorized Signature ________________________________
Date: ________________
Relationship to patient ________________________________
OFFICE USE ONLY
Date release requested:
_____________
Date records released:
___________
Pediatric & Adolescent Dentistry and Orthodontics for Children
Arnold I. Weiss, D.D.S. · Wesley T. Barton, D.M.D. · Ronen Krausz, D.D.S. · Roger Taylor, D.M.D.
1560 Beacon Street Brookline, MA 02446
T: (617) 731-5437

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