Protected Health Information –Dental Record
Authorization for Release
The Oaks Dental Center, Ltd. -- Agnes Kumar, DDS
Patient Last Name, First Name *
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Patient Street Address *
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Patient Phone/Email ID *
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Patient Date of Birth *
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Recipient Person/Facility Name
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Recipient Person/Facility Address & Phone
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Recipient Person/Facility Email ID (for electronic transfer)
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Information to be Released
Purpose of Information Release
I do hereby authorize The Oaks Dental Center, Ltd. to release a copy of my dental record to the person or facility below. *
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Print your name below *
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Today's Date *
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If signed by anyone other than the patient, state the relationship to patient and/or legal authority for signing
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