BALA INSTITUTE OF ORAL SURGERY AUTHORIZATION TO RELEASE DENTAL RECORDS

Authorization To Release Dental Records
Patient Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*

Area CodePhone Number
Email*
example@example.com
Patient Date of Birth:*

MonthDayYear
Date
DISCLOSE TO:*

SelfDental ProviderHealthcare ProviderOther
DELIVERY OPTIONS:*

MailEmailFax (Cannot fax x-rays)Pick up
PICK UP (photo ID is required):

I hearby authorize:Other
INFORMATION REQUESTED:*

Copy of dental recordsDental x-raysCopy of billing records
SEND RECORDS TO:

Send records:Other
ADDRESS TO SEND RECORDS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for request
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
When transferring information, we only send records within the last five years.
Please send records directly to the patient and not a facility/physician
I hereby authorize Bala Institute of Oral Surgery to provide copies of my dental records with respect to any dental care and treatment that I have received.
Signature of Parent or Legal Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Authorization To Release Dental Records