Authorization to Release Dental Information

Patient's Name

Date of Birth

Release to:

I request and authorize the above-named doctor or healthcare 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)

Drug Abuse, If any

Sickle Cell Anemia, If any

Alcoholism or alcohol abuse, If any

Psychological or psychiatric conditions, If any

INFORMATION REQUESTED

DATE COVERED

Copy of complete dental chart

($12.50 minimum fee based on # of pages)

All treatment rendered in this office

Copy of dental x-rays

Limited to treatment dates & for conditions described below

Other (e.g. models-describe)

PURPOSE(S) OR NEED FOR WHICH INFORMATION IS TO BE USED

Transfer of Records

Second Opinion

Other Claim evaluation

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 for disclosure, but any event on (please fill below) revoked in writing by patient, or (please fill below) 180 days from the date hereof (please fill below) under the following conditions:

Event on

date supplied by patient

Days

Date hereof

OTHER CONDITIONS: A copy of this authorization or my signature thereon my or may not be used with the same effectiveness as the original

Patient Signature

Date

PERSON AUTHORIZED TO SIGN FOR PATIENT

STATE HOW AUTHORIZED

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