Authorization for Release of Orthodontic Records

I, _______________________ (print patient name), DOB: ____________, hereby authorize:

Release From:

Practice Name: ___________________________________ Doctor's Name: ___________________________________ Address: ________________________________________ Phone: _________________ Fax: ___________________

Release To:

Practice Name: ___________________________________ Doctor's Name: ___________________________________ Address: ________________________________________ Phone: _________________ Fax: ___________________

Records to be Released (check all that apply):

• Complete orthodontic records
• Treatment plans and progress notes
• Digital/physical orthodontic models
• Radiographs (panoramic, cephalometric)
• Intraoral/extraoral photographs
• Financial records
• Other: _____________________________________

Purpose of Release:

• Continuing Care
• Transfer of Care
• Legal Purposes
• Insurance
• Personal Records
• Other: _____________________________________

Authorization

I understand that:

1. This authorization expires one year from the date signed
2. I may revoke this authorization in writing at any time
3. Treatment is not conditional upon signing this authorization
4. Information used or disclosed may be subject to re-disclosure
5. A copy of this authorization is as valid as the original

Signature: _________________________ Date: __________ (Parent/Guardian if patient is under 18)

Print Name: _________________________

Relationship to Patient: _________________________