Authorization for Release of Dental Records

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Records to be Released From

Practice Name: _________________ Dentist Name: __________________ Address: _______________________ Phone: ________________________ Fax: __________________________

Records to be Released To

Practice Name: _________________ Dentist Name: __________________ Address: _______________________ Phone: ________________________ Fax: __________________________

Information to be Released

(Check all that apply)

□ Complete Dental Record □ X-rays and Imaging □ Treatment Plans □ Financial Records □ Other: ______________________

Purpose of Release

□ Continuing Care □ Insurance □ Legal □ Personal Records □ Other: ______________________

Authorization

I understand that:

1. This authorization is valid for 90 days from the date of signature
2. I may revoke this authorization in writing at any time
3. Information disclosed may be subject to redisclosure by the recipient
4. Treatment is not conditional upon signing this authorization

Signature: ____________________ Date: ________________________

If signed by legal representative: Relationship: _________________

Practice Use Only

Date Received: ________________ Processed By: _________________ Date Completed: ______________