Authorization For Release Of Dental Records

Information you will need

• What’s the client's printed name?
• What's the client's name?
• What's the client's date of birth?
• What's the client's SSN?
• What's the initiator's relationship to the client?
• Who's authorized to disclose the dental records?
• Who's authorized to receive the dental records?
• When will this authorization terminate?
• On what date is this authorization being initiated?
• What treatment or condition?
• What years?
• What dates?
• Does this authorization include dental records spanning a specific number of years?
• Does this authorization include dental information for a specific treatment/condition?
• Does this authorization include dental records for specific dates?
• Does this authorization include all of the client's dental records?
• Should information about HIV/AIDS be released?
• Should information about drug and/or alcohol abuse be released?
• Is this authorization made for insurance coverage purposes?
• Is this authorization made for employment purposes?
• Is this authorization made for marketing purposes?
• Is this authorization made for the purposes of treatment, payment, or health care operations?
• Is this authorization made for other reasons?
• On what date will this authorization terminate?

…and 8 more fields in the PDF.

Completed by the provider and the client and the recipient.

The form includes 2 signature lines.