Release of Information Form

Authorization for Release of Dental Information

Many of our adult patients allow family members such as their spouse, parents or others to request dental information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental information released you must sign this form. Signing this form will only give information to the person indicated below.
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Name of Person to Release Information To*

First NameLast Name
Consent*

I hereby give you permission to release any and all of my dental records to the person listed above.
Signature*

Clear
Should be Empty:

Authorization for Release of Dental Information