Records Release Form

Records Release Form

AUTHORIZATION TO RELEASE DENTAL INFORMATION
To Dr:
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Release to:

Dr. Steven Oshins

info@oshinsofsmiles.com

I request and authorize the above-named doctor or health care provider to release the information specified below to the organization, agency or individual named on this request. I understand that the information to be released includes information regarding the following condition(s):
INFORMATION REQUESTED:

Other
PURPOSE OR NEED FOR WHICH THE INFORMATION IS TO BE USED:

Other
I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken to comply with it. With my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event: on the date of this form's signature; or if revoked in writing by patient; or 180 days from the date hereof; or under the following conditions:
Patient's Name

First NameLast Name
Person Authorized to Sign for Patient

First NameLast Name
State How This is Authorized
Signature of Patient or Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: