AAC/SDH Authorization for Release of Protected Health Information Logo
  • Authorization for Release of Protected Health Information

    Please Complete this form thoroughly. You or your dependent(s) dental records can not be released until this form is completed and signed by the patient (or if under 18 their parent or legal guardian). *** After this form is completed it will then be presented to the doctor for approval. In some cases it may take up to TEN (10) days for records to be released.
  •  - -
  •  -
  •  -
  •  -
  • This authorization is valid for 90 days and may be revoked at any time in writing prior to the expiration date. Additional authorization for disclosure beyond the recipient is required.

  • Clear
  • Should be Empty: