Get the free BAUTHORIZATIONb TO bRELEASEb DENTAL INFORMATION

AUTHORIZATION TO RELEASE DENTAL INFORMATION (The execution of this form does not authorize the release of information other than the terms specifically described below.) TO: PATIENT NAME: FAX: DOB:

How to fill out bauthorizationb to breleaseb dental

How to fill out authorization to release dental records:

1. Start by obtaining the necessary form. Many dental offices have their own specific authorization forms, so you may need to ask your dentist or dental office receptionist for the appropriate document.
2. Begin filling out the form by providing your personal information. This usually includes your full name, date of birth, address, and contact information.
3. Next, indicate the purpose of the authorization. Specify that you are granting permission for the release of your dental records.
4. Include the name and contact information of the dental provider or office from which you are authorizing the release of records. This should include the name of the dentist or dental office, their address, phone number, and any other relevant contact details.
5. Specify the time period for which the authorization is valid. You can choose a specific timeframe or indicate that it is ongoing until you revoke the authorization.
6. Sign and date the form to validate your authorization. Ensure that you have read and understood the terms of the authorization before signing.

Who needs authorization to release dental records?

1. Patients who are switching dental providers may need to provide authorization to release their dental records to their new dentist. This allows the new dentist to review their dental history, X-rays, and any other relevant information related to their oral health.
2. Individuals who are seeking a second opinion or consulting with dental specialists may need to authorize the release of their dental records to these professionals.
3. In some cases, patients may request their dental records for personal reasons, such as keeping track of their dental history or providing documentation for legal or insurance purposes. In such instances, they would need to authorize the release of their dental records to themselves.

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