Dental Patient HIPAA Release Form
Patient Information
Patient Name
Date of Birth
Phone Number
Release of Information
Name(s) of person(s) or organization(s) to receive information
Relationship to Patient
Information to be Released (please specify)
Purpose of Release
Expiration Date or Event
I understand that I have a right to revoke this authorization at any time.
Patient Signature
Date
If signed by a personal representative, relationship to patient