Patient’s Name:_________________________________Date of Birth: _________________
SSN:_____________________________ Treating Endodontist: _______________________
I request and authorize the above listed endodontist and practice to release health care information of the patient named above to:
City: _____________________________________ State: ______________ Zip: ________
Or _____ All health care information
I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it. Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, or on ____-____-20___ or must be revoked in writing by the patient. If it is revoked in writing the document must contain the statement that the patient wants to cancel their authorization to disclose health care information. It must also contain the name or other specific identification to the person (s) that the patient no longer wants to receive information and must be signed and dated.
Once my endodontist gives out the information that I want released, I know that my endodontist has no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or state privacy laws no longer protect the information.
A copy of this authorization or my signature thereon: _____may, or _____may not be used with the same effectiveness as an original.
PATIENT NAME (print) PATIENT SIGNATURE
PERSON AUTHORIZED TO SIGN FOR DATE
STATE HOW AUTHORIZED
To request your patient records – Fill out and Fax this form to 719.599.8599 or email firstname.lastname@example.org attn: Laura B