Form

Patient Authorization To Release Records

First Name

Last Name

Date Of Birth

NAME OF PREVIOUS DENTIST:

OFFICE ADDRESS:

OFFICE PHONE

OFFICE FAX:

As required by the privacy regulations, this practice may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization. Under the Connecticut State Statues, this information cannot be transmitted to anyone else without explicit consent or through other authorizations as provided in the statues of the state of Connecticut.

I hereby authorize this office and any of its employees to use or disclose my patient health information to the following person(s) or entity.

Please Forward all dental records taken in the past 5 years to:

For adult Patients 18+: info@galesferrydentistry.com

For Pediatric Patients Under 18: pedo@galesferrydentistry.com

Dr. Randall Harris

1527 Route 12

PO Box 396

Gales Ferry, CT 06335

(860) 464-7204

Patient/Legal Guardian Signature

Date