Spann Release of information

Please enter your full name *

CHRISTA D. SPANN, DMD

5500 Summerville Road

Phenix City, AL 36867

(334)297-7100, (334)297-7065 fax

(This office charges a $25 records fee)

AUTHORIZATION TO RELEASE DENTAL INFORMATION

(The execution of this form does not authorize the release of information other than the terms specifically described below.)

Patient Name *

Patient date of birth *

Patient Social Security Number *

Phone *

Initial agreement here *

Release to the office *

I request and authorize the above-named doctor or health care provider to release the information specified below to the organization, agency or individual named on this request. I understand that the information to be released includes information regarding the following condition(s):

INFORMATION REQUESTED:

DATES COVERED: *Limited to treatment dates and for *

Copy of complete dental chart condition described below: *

Yes

Copy of dental x-rays *

Yes

All treatment rendered *

Yes

PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

Transfer of Records *

Yes

Second Opinion *

Yes

AUTHORIZATION: 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. With my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event: on_______________(date supplied by patient;
or______ if revoked in writing by patient;
or______180 days from the date hereof; or______under the following
conditions:_____________________________________________________________.

(note: use spaces below to add the blank line information)

Add on date here

Add if revoked date here

Add 180 days from date here

Add following conditions here

Patient Full Name *

Date * +

Person authorized to sign form patient (if needed)

State how you are authorized to sign for the patient (if needed)

Please sign using mouse *

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