Authorization to Release Dental Information

Authorization to Release Dental Information
TO
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PATIENT NAME
DATE OF BIRTH

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Please release the information requested below to the following person/office:

PROVIDER: Smile Essentials/Carolyn Kittell D.D.S
ADDRESS: 8200 E Belleview Ave, Ste. 435-E, Greenwood Village, CO 80111
PHONE: (303) 779-9472
FAX: (303) 779-4176
EMAIL: info@smileessentialsdental.com
Purpose of Transfer

Permanent Transfer of RecordsClaim EvaluationSecond OpinionEvaluation by SpecialistOther
INFORMATION REQUESTED:
Information Requested

Copy of Complete Dental CharteCopy of Dental X-Rays: Please include dates taken.Other (models, etc)
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. Without my express revocation, this consent will automatically expire upon satisfaction of the need to disclosure, 180 days from the date of signed consent.
SIGNATURE

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PRINTED NAME
DATE

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