I hereby authorize Dr. Alan S. Lee, DDS to release my dental records and/or health information to the recipient listed below. This authorization is valid for one year from the date of signature unless otherwise revoked in writing. I understand that I may revoke this authorization at any time by submitting a written request to the dental office.
Patient Full Name
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First Name
Last Name
Date of Birth
*
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Month
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Day
Year
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Recipient Name (doctor, office, or insurer)
*
Recipient Address
Recipient Fax or Email
Type of Records to Release
*
Complete dental records,X-rays and imaging,Treatment notes,Billing and insurance records,Other (specify below)
Additional Information / Special Instructions
Patient / Guardian Signature
*
Date
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Month
-
Day
Year
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Submit
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