Authorization to Request Dental Records - Inwood Family Dental : Inwood Family Dental

Authorization to Request Dental Records from Outside Office on Behalf of Patient

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PATIENT INFORMATION:

Full Name:

First

Last

Date of Birth:

Phone Number:

AUTHORIZES INWOOD FAMILY DENTAL TO REQUEST RECORDS FROM:

Name of Dental or Specialist Practice:

Phone Number:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Last Date of Treatment (Month/Year):

INFORMATION REQUESTED:

Copy of Complete Dental Chart
Copy of Dental X-Rays (Email preferred)
Copy of Periodontal Charting
Other (models, scans, etc.)

AUTHORIZATION:

I request and authorize the above-named healthcare provider to release the information specified above to Inwood Family Dental – Dr. Selina Gutierrez. I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that this authorization is good for one year, unless the dates are filled in below:

Layout

From Date

I may revoke this Authorization at any time in writing, except to the extent that action has already been taken to comply with it.

Patient Name

First

Last

Signature of Patient/Legal Representative:

Relation to Individual:

Date Signed