Medical Records Release Form

Medical Records Release Form
21260 S. Springwater Rd | Estacada, OR 97023 Phone: 800-279-3104 | Fax: 949-798-6979 | dentalinfo@dedicatedsleep.net | dedicatedsleep.net
Patient’s Name:
Date of Birth:

MonthDayYear
Date
By Signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/person/facility/entity listed:

Dedicated Sleep 21260 S. Springwater Rd Estacada, OR 97023
Patient Signature:

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