Medical Records Release

Doctor Referral - Dental
* required field

Authorization for Medical Records Release

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







The Information is to be provided to



Please sign below to complete the form

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


This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Under HIPAA with a patient's written request, records must be provided within 30 days of a request



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