Form

Release of Information

First Name

Last Name

Email

Date Of Birth

Release of Information

Release of Information

Records may be released FROM:

Dental Office Name (Previous/Transferring From)

Office Phone

Office Email

Address

City

Zip Code

Records may be released TO:

Dental Office Name (New/Transferring To)

Office Phone

Office Email

Address

City

Zip Code

Reason for Disclosure:

If Other:

I certify that this request has been made voluntarily and that the information given above is correct to the best of my knowledge. I understand that I may revoke this authorization at anytime, except to the extent that the action has already been taken to comply with this request.

Once my doctor gives out the information that I want release, I know what my doctor has no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or state privacy laws may no longer protect the information.

Consent

Date