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Authorization to Release Dental Information Form

Authorizes a dental office to send a patient's dental records to another provider or to an insurance company.

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Date of Birth

Patient Name

Nombre

Apellido

Phone Number

Release Dental Records To

Another Dentist Insurance Company Specialist The Patient Themselves

Delivery Methods

Mail Fax Email Pick Up in Person

First Name

Please Upload a Photo

Max 10 MB per file

Mailing Address

Dirección

Ciudad

Estado / Provincia

Código postal

Fax #

Records Requested for the Period:

From

Information to Be Disclosed

X-Rays Treatment History Billing Records Clinical Notes

If You Have Specific Instructions or Specific Information Not to Be Disclosed, Please Explain Them Here.

Or Specify an Alternate Period:

From

Date

Signature

Sign here

If the Signature Is Other Than the Patient's, Please Complete the Following. The Signature Belongs To:

Patient Parent or Guardian Legal Representative

Name

Nombre

Apellido

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