Authorization for Release of Dental Records

Patient Information

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

Records to be Released (check all that apply)

• Complete dental records
• Periodontal charting
• Radiographs (X-rays)
• Clinical photographs
• Treatment plans
• Progress notes
• Financial records

Release Records From

Practice Name: __________________ Provider Name: _________________ Address: _______________________ Phone: ________________________

Release Records To

Practice Name: __________________ Provider Name: _________________ Address: _______________________ Phone: ________________________

Authorization

I, _________________________, authorize the release of my dental records as indicated above. 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 used or disclosed pursuant to this authorization may be subject to redisclosure
4. I have the right to receive a copy of this authorization

Signature: ______________________ Date: _______________

For Office Use Only

Request received: ________________ Records sent: ___________________ Staff initials: __________________