Authorization for Release of Endodontic Records

Patient Information

• Full Name: _________________________ Date of Birth: _____________
• Address: ________________________________________________
• Phone: _____________________ Email: ______________________

Records to be Released (check all that apply)

• Clinical Notes
• Radiographs (X-rays)
• CBCT Scans
• Treatment Plans
• Billing Records
• Other (specify): ______________________

Release Records From

Practice Name: ________________________________________________ Doctor's Name: ________________________________________________ Address: _____________________________________________________ Phone: _______________________ Fax: ___________________________

Release Records To

Practice/Individual Name: _______________________________________ Address: _____________________________________________________ Phone: _______________________ Fax: ___________________________ Email: _______________________________________________________

Authorization

I understand that:

1. This authorization is valid for 90 days from the date of signature
2. I may revoke this authorization in writing at any time
3. Information disclosed may be subject to redisclosure by the recipient
4. I have the right to receive a copy of this authorization

Signature: _________________________ Date: ___________________

For Office Use Only

Request received by: _________________ Date: ___________________ Records sent by: ____________________ Date: ___________________ Delivery method: [ ] Fax [ ] Email [ ] Mail [ ] Hand-delivered