Release Authorization

AUTHORIZATION TO RELEASE DENTAL INFORMATION
TO:
PATIENT NAME:
FAX:
DOB:
SSN:
RELEASE TO:
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:

Copy of complete dental chartCopy of dental x-raysAll treatment renderedOther
DATES COVERED (Limited to treatment dates and for condition described below):
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. With 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 may, or may not be used with the same effectiveness as an original:
MayMay not
Patient Name
Person authorized to sign for patient
State how authorized
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION TO RELEASE DENTAL INFORMATION