Request For And Authorization To Release
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1EAST TAYLOR DENTAL
Killian J. Horner, DDS
2201 Taylor Road Montgomery, Alabama 36117
Office 334-271-4600
Fax 334-271-4709
REQUEST FOR AND AUTHORIZATION TO RELEASE
MEDICAL TREATMENT INFORMATION
This form is submitted on behalf of our mutual patient:
______________________________________________________________________
Patient Name
DOB
Social Security#
The patient referenced above has agreed to inquire and request the prompt release of
his/her medical information indicated below:
Medical Diagnostic
Medical Treatment
Laboratory & X-ray Results
Prescription medication history
Most Recent Sleep Study
When (date/year) was the study performed? __________________
Where (name/address of facility) was the study performed?
_________________________________________________
Who ordered the Sleep Study?_________________________
Accident Related Information
Work Comp
MVA
Date of Accident: _______________________________________
Insurance Carrier Information:
______________________________________________________
If Work Comp, name & number of supervisor approving treatment.
__________________________________________________
Supervisor Name
Phone
Please submit the information indicated above to the following address:
East Taylor Dental
2201 Taylor Road
Montgomery, Alabama 36117
You may fax information to the following number: 334-271-4709, Attn: Mindy
My signature below signifies my request and hereby indicates my authorization for my
doctor to provide my dentist, Dr. Killian Horner, with my medical treatment information.
Date______________ Signature_____________________________________________
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