Authorization For The Release Of Dental Information printable pdf download

Authorization For The Release Of Dental Information

Luck Dental Clinic, Inc.

308 First Street South

PO Box 550

Luck, Wisconsin 54853

Phone: (715) 472-2211• Fax: (715) 472-4485

Authorization for the release of dental information

To:

_______________________________________________

Health Care Provider

_______________________________________________

Street Address

_______________________________________________

City

State

Zip Code

(_____)________________________________________

Telephone no.

You are hereby authorized to release to ___________________________ and its

representatives any and all information you may have concerning my dental condition,

including x-rays, which you have obtained as a result of history, examinations, testing,

diagnosis, treatment and prognosis.

This authorization shall remain valid for one year from today’s date. A signed copy of

this authorization and DO / DO NOT (circle one) request a copy, and if requested, do

acknowledge a receipt thereof.

I have read this authorization before signing it.

___________________________________

Print or type name

______________

___________________________________

Date

Signature

If not signed by the patient, please indicate relationship:

[ ] parent or guardian of minor patient

[ ] guardian or conservator of incompetent patient

[ ] beneficiary or personal representative of deceased patient

Authorization For The Release Of Dental Information