southmountainfamilydentistry.com - Dental Records Release Form

Patient Dental Records Release
Patient Information
Patient Name
Patient’s Date of Birth

MonthDayYear
Date
Authorization Details
Signer Name
Signer Email
example@example.com
Release to Dental Office
Dental Office Name
Dental Appointment Date

MonthDayYear
Date
Dental Office Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Office Email
example@example.com
Release to Parent/Guardian
Guardian Name
Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

AUTHORIZATION TO RELEASE DENTAL INFORMATION

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

MonthDayYear
Date
SSN:
RELEASE TO:
I request and authorize the above-named doctor or health care provider 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):
INFORMATION REQUESTED:

Copy of complete dental chartCopy of dental x-raysAll treatment renderedOthers (e.g. models—describe)
DATES COVERED: ***Limited to treatment dates and for condition described below**
PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

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. With my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event: on Date (date supplied by patient; or if revoked in writing by patient; or 180 days from the date hereof; or under the following conditions: Type a label

OTHER CONDITIONS: a COPY of this Authorization or my signature thereon may or may not be used with the same effectiveness as an original.
Patient Name
Date

MonthDayYear
Date
Person authorized to sign for patient

Clear
State How Authorized
Should be Empty:

Patient Dental Records Release

Patient Information

Authorization Details

Release to Dental Office

Release to Parent/Guardian

AUTHORIZATION TO RELEASE DENTAL INFORMATION