Authorization for Release of Medical Records - Oral Surgery

Patient Information

Full Name: _________________________ Date of Birth: ______________ Address: ___________________________ Phone: ____________________

Records To Be Released From

Practice Name: ______________________ Provider Name: ______________________ Address: ___________________________ Phone: _____________ Fax: ___________

Records To Be Released To

Practice Name: ______________________ Provider Name: ______________________ Address: ___________________________ Phone: _____________ Fax: ___________

Information to be Released

(Check all that apply)

• Complete Dental Records
• X-rays and Imaging
• Treatment Plans
• Surgical Notes
• Billing Records
• Other: ______________

Date Range

From: _____________ To: _____________

Purpose of Release

• Continuing Care
• Insurance
• Legal
• Personal Records
• Other: ______________

Authorization

I understand that:

• This authorization is valid for 90 days from the date of signature
• I may revoke this authorization in writing at any time
• Information used or disclosed may be subject to redisclosure
• I have the right to receive a copy of this authorization
• Treatment is not conditional upon signing this authorization

Signature: _________________________ Date: ______________

If signed by representative: Name: _____________________________ Relationship: _________

For Office Use Only

Request received by: ________________ Date: ______________ Records released by: ________________ Date: ______________