AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient Name

Date of Birth

Previous Name

Social Security #

I request and authorize David E. Morgan, DDS, PLLC, dba Morgan Family Dentistry release healthcare information of the patient named above to any and all healthcare providers which may be deemed necessary or appropriate as requested by me or recommended by David E. Morgan, DDS via mail, shipping service, e-mail (unencrypted or otherwise), fax, phone conversation or any other form or manner without special security precautions and may specifically indude but is not limited to me, someone I designate over the phone or in writing and/or the below:

Name

Address

City

State

Zip Code

This request and authorization applies to all records possessed by David E. Morgan, DDS, PLLC, dba Morgan Family Dentistry now or in the future which may or may not include but is not limited to diagnosis, treatment notes, treatment plans, payment records, health history and all other forms, documents and information, impressions and models, radiographs and photos.

I understand that I do not have to sign this form and my dental care in this office will not be affected by this decision. I also understand if I don't sign this form Morgan Family Dentistry may ask me to obtain and deliver this information myself. There is risk information might be unlawfully obtained when transferred from one provider to another or any other time and if this happens the information may be disclosed and no longer protected by privacy law. I do not hold David E. Morgan, DDS or Morgan Family Dentistry liable should such disclosure occur now or at any time in the future.

Signature

Patient Name Printed

Signature of Patient

Parent or Guardian Name

Signature of Parent or Guardian

Date Signed

THIS AUTHORIZATION IS ACTIVE UNTIL REVOKED BY PATIENT IN WRITING.

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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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