Release of Protected Health Information Information Release Authorization to Release Health Information to Fairmount DentalPatient First Name* Patient Last Name* Date of Birth* MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code By signing this form, I authorize the following:I hereby request and authorize you, your authorized employees and/or agents, permission to send copies, disclose and/or discuss my dental health care information in your possession to Fairmount Dental at frontdesk@fairmountdental.meName of Dental Practice* Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Practice Phone Number*Practice Email Health Information to Be Disclosed* Clinical Notes X-Rays Entire record (Check all that apply.)My authorization to release includes:Copies of my medical, social and dental histories, clinical exam and diagnostic records, radiographs, clinical photos, treatment plans, treatment progress records, referral and consultation recommendation and notes, diagnostic and working casts, pharmaceutical, medical and dental lab prescriptions and results, office notes and other related records that would assure continuity of my dental care. I understand I may request a copy of this authorization. By signing below, I hereby release the holder from all liability, and claims pertaining to this transfer of healthcare information. I understand that any refusal to release or revocation of this consent may result in improper diagnosis or treatment. I understand that I may review all information before its release. Signature of Patient* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Signature of Legal Representative Reset signature Signature locked. Reset to sign again Relationship to Patient Date MM slash DD slash YYYY CAPTCHA
