Patient Authorization To Release Confidential Information

Patient Name

Date of Birth

I hear by, request and authorize

Baumrind Family Dentistry

100 Peachtree Street, Suite 1820

Atlanta, Georgia 30303

to disclose and provide copies of all clinical treatment records and information concerning my care, which is in the possession of this person or entity, to/ from:

(Name of New Dentist, Practice, Specialist, Consultant, etc.)

Address of Employer

City

State

Zip

Phone Number

These records include, but are not limited to: personal patient Information, medical and dental histories, examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and other related materials.

I expressly release from liability the above-named person or entity from all liability arising from compliance with this request and disclosure of the requested information.

Signature of:

Patient

Parent

Legal Guardian

Other

Name

Signature

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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