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SHAW Dental Services Portland State University Phone: 503.725.2611 Fax: 503.725.2620 527 SW Hall St. Portland, OR UCB Suite 309Authorization to Release Dental Information Patient Name: ___ Date of
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How to fill out authorization to release dental
How to fill out authorization to release dental
01
Contact your dental provider to request an Authorization to Release Dental form.
02
Fill out your personal information, including your full name, date of birth, and contact information.
03
Specify the information you would like to release and to whom.
04
Sign and date the form to authorize the release of your dental records.
05
Return the completed form to your dental provider either in person or by mail.
Who needs authorization to release dental?
01
Anyone who wishes to have their dental records released to a third party, such as another dentist or insurance company, will need authorization to release dental.
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What is authorization to release dental?
Authorization to release dental is a form that allows a dental office to release a patient's dental information to a third party, such as another healthcare provider or insurance company.
Who is required to file authorization to release dental?
The patient or legal guardian is required to file the authorization to release dental.
How to fill out authorization to release dental?
Authorization to release dental is typically filled out by providing the patient's name, date of birth, dental office information, the recipient of the information, and the specific information being released.
What is the purpose of authorization to release dental?
The purpose of authorization to release dental is to ensure that patient's dental information is protected and only disclosed with permission.
What information must be reported on authorization to release dental?
The authorization to release dental must include the patient's name, date of birth, specific information being released, recipient of the information, and the purpose of the release.
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