www.titusdentistrymiddletown.com - AUTHORIZATION TO RELEASE DENTAL INFORMATION

AUTHORIZATION TO RELEASE DENTAL INFORMATION

(The execution of this form does not authorize the release of information other than the terms specifically described below.)
PATIENT NAME*

First NameLast Name
PATIENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER*
Please enter a valid phone number.Format: (000) 000-0000.
DATE OF BIRTH*

MonthDayYear
RELEASE RECORDS TO
PHONE NUMBER*
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL*
example@example.com
I request and authorize Titus Dentistry 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):
Copy of dental x-rays
Most Recent X-raysDental x-rays for specific dates
Dental x-rays for specific dates*
Transfer of RecordsSecond OpinionOther
Please Explain*
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. This consent will automatically expire upon satisfaction of the need for disclosure, on (date supplied by patient); or if revoked in writing by patient; or 180 days from the date hereof. A copy of this Authorization or my signature thereon may be used with the same effectiveness as an original.
Patient Name (Print)*

First NameLast Name
Person authorized to sign for patient if not patient
Signature *

Clear
State how authorized
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: