LaTOOTH DOC
Authorization for Release of Dental Records
Patient Information:
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Releasing Provider: Wurzbach Parkway Family Dental
Receiving Provider: La Tooth Doc
Dr. Tracy Walters-Badillo, DMD
1418 Walkers Way
San Antonio, TX 78216
Phone: 210-759-4999
Records Requested:
Complete Dental Record
X-Rays / Imaging
Periodontal Records
Treatment Notes
Billing Records
Other
Purpose of Disclosure:
I authorize the release of my dental records as indicated above. I understand that this authorization allows the release of my confidential health information to the recipient named. I understand that I have the right to revoke this authorization at any time by providing a written request, but that such revocation will not apply to information already released in reliance on this authorization.
I have read and understand the above authorization.
Signature:
Date:
-
Month
-
Day
Year
Date
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Should be Empty: