Dr. Cruz - Authorization to Release Dental Information

Authorization To Release Dental Information
To:
Patient Name:

First NameMiddle NameLast Name
Fax:
DOB:

MonthDayYear
Date
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 information regarding the following condition(s):
INFORMATION REQUESTED:

Other
DATES COVERED:
*Limited to treatment dates and for condition described below:
PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

Other
Patient Signature
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Authorization To Release Dental Information