Dental Records Release Authorization

Submission Reference: [Submission Reference]
Date of Submission: [Submission Date]

Patient Information

First Name: [Patient First Name]
Last Name: [Patient Last Name]
Date of Birth: [Date Of Birth]

Release Information

Release To: [Release To]
Phone Number: [Phone Number]
Email Address: [Email Address]

Street Address: [Street Address]
Street Address Line 2: [Street Address Line 2]
City: [City]
State / Province: [State Province]
Postal / Zip Code: [Postal Zip Code]

By signing this form, I, [Patient First Name] [Patient Last Name], authorize the disclosure of my dental records to the individual or entity listed above.
Expiration Date of Authorization: [Expiration Date]

Terms and Conditions

This authorization is voluntary and shall remain effective until the expiration date specified above unless revoked in writing. I understand that my treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization. I understand that information disclosed by this authorization might be re-disclosed by the recipient and may not be protected by federal or state privacy laws.

Signature Date:  [Submission Date]