Medical Records Release

Doctor Referral - Dental

* required field

TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN THIS FORM

I herby voluntarily authorize the disclosure of information from my health record. (Name of Patient) *

Address

Date of Birth *

Record Number

Information Requested *

Purpose of Release *

Name of Person/Facility/Organization *

Phone Number

Checking this box will serve as your electronic signature to verify that all information above is accurate and correct. *

Name of Patient or Patient Representative *

Relationship to Patient

Security Measure