Form

Patient Authorization Form

Authorization to Release Information

Under the requirements for H.I.P.A.A. we are not permitted to release information to anyone without patient's written consent. If you wish to have your dental information, any diagnostic test results and/or financial information released you must sign this form.

First Name

Last Name

Date Of Birth

I authorize Gales Ferry Family Dentistry to release my records and any information to the following individuals:

Name:

Relation to Patient:

Name:

Relation to Patient:

Name:

Relationship to Patient:

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

Patient/Legal Guardian Signature

Date