Release of RecordsRelease of RecordsPatient Name*Date of Birth*Social Security Number*Day Time PhoneEvening PhoneInformation to Be Released From:Name of DentistDental Practice NameAddressPhone NumberFax NumberE-Mail AddressI hereby authorize the release of the above information contained in my dental records which may contain personal and confidential information. I release you from any legal responsibility or liability that may result from this authorization. Authorization is valid for 90 days and may be revoked in writing any time prior to 90 day by notifying the releasing party.Information Release Authoritzation*AgreeP.O. Box 4935 Jackson, Wyoming 83001, (307) 733-4778, (307) 734-8041 (fax), teeth@larsenfamilydentistry.comSendThis field should be left blank
