Authorization to Release Dental Information Form

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

To:

Patient Name:

Fax:

Date of Birth:

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 chart

Copy of dental x-rays

All treatment rendered

Others (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 Records

Second Opinion

Other, 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 (Please state date below).

Radio buttons

or if revoked in writing by patient or 180 days from the date hereof or under the following conditions:

Conditions

OTHER CONDITIONS

A COPY of this Authorization or my signature thereon:

May May not

be used with the same effectiveness as an original.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name (Print):

Date:

Name of the person completing form

Signature / Person authorized to sign for patient:

State how authorized:

Your information will be encrypted.