Form

DENTAL RECORDS RELEASE AUTHORIZATION

I am requesting release of records on behalf of:

Reason for Disclosure:

Release Records:

First Name

Last Name

Date Of Birth

Address

City

State

Zip code

Release of Information FROM:

Lindsey Dentistry PLLC

Dr. Lindsey A. George DDS

261 Main Street - PO Box H Claysville, PA 15323

Dentist/Facility Name

Dentist/Facility Phone

Dentist/Facility Fax

Dentist/Facility Email

Dentist/Facility Address

Dentist/Facility City

Dentist/Facility State

Dentist/Fa Zip code

Release of Information TO:

Acceptable means of delivery

Lindsey Dentistry PLLC

Dr. Lindsey A. George DDS

261 Main Street - PO Box H

Claysville, PA 15323

Practice@LindseyDentistry.com

Fax: (724) 566-4179

Dentist/Entity Name

Dentist/Entity Phone #

Dentist/Entity Fax #

Dentist/Entity Email

Dentist/Entity Address

Dentist/Entity City

Dentist/Entity State

Dentist/En Zip code

Form of Disclosure:

Release of Information

Patient/Guardian First Name

Patient/Guardian Last name

Patient/Guardian Consent

Date