Authorization to Release Dental Information Form

Please correct the errors described below.

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

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:

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DATES COVERED:

PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

AUTHORIZATION:

OTHER CONDITIONS

may not be used with the same effectiveness as an original.

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