Authorization for Release of Dental Records

AUTHORIZATION FOR RELEASE OF DENTAL RECORDS

Please include all records and radiographs for the below mentioned patient & their spouse/family members if inidcated. Thank you!

Patient Name *

First

Last

Date of Birth *

Please apply this release to the above patient’s:

Spouse
Children

The above listed patient has authorized the release of dental records and radiographs to:

Dr. Corey Cook, DDS
609 W South St
Mason, MI
Ph: 517-676-9566
Fax: 517-676-0318 frontdesk@ccookdds.com

Authorization and Release *

I authorize the release of my personal and confidential information as described above. I understand that this is voluntary and that the information is protected by law. I understand it is within my rights to withdraw consent in writing at any given time. This is in accordance with the Health Information Portability and Accountability Act (HIPAA) .

By signing this release form, you agree to be bound by, and to comply with the Authorization & Release Conditions. If you do not agree to release your dental information, please do not use tick the box.

Patient's Signature *

Clear Signature

Typed Name

Date *

Patient's under to

Parent/Guardian SIgnature (if under the age of 18)

Clear Signature

Typed Name

Date

Authorization for Release of Dental Records

Dr. Corey Cook, DDS 609 W South St Mason, MI Ph: 517-676-9566 Fax: 517-676-0318 frontdesk@ccookdds.com

Dr. Corey Cook, DDS
609 W South St
Mason, MI
Ph: 517-676-9566
Fax: 517-676-0318 frontdesk@ccookdds.com