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Home
Office
About Our Doctor
Our Staff
Financial
Map and Directions
Latest News and Updates
Office Photos
Appointment Request
Patients
First Visit
Patient Forms
Patient Gallery
FAQ
Patient of the Month
Brushing and Flossing with Braces
Common Problems
Emergency Info
Foods to Avoid
Patient Rewards
Glossary
Treatment
Damon Braces
Invisalign
Invisalign Teen
Early Treatment
Adult Treatment
Case Studies
Retention
Articles in Orthodontics
AcceleDent
Virtual Smile Consult
Contact Us
Fort Collins Office
Wellington Office
Windsor Office
Medical Records Release
Doctor Referral - Dental
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required field
Authorization for Medical Records Release
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)
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Address
Date of Birth
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Record Number
Information Requested
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Purpose of Release
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The Information is to be provided to
Name of Person/Facility/Organization
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Phone Number
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.
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Name of Patient or Patient Representative
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Relationship to Patient
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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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