AAC/SDH Authorization for Release of Protected Health Information

Authorization for Release of Protected Health Information

Please Complete this form thoroughly. You or your dependent(s) dental records can not be released until this form is completed and signed by the patient (or if under 18 their parent or legal guardian). *** After this form is completed it will then be presented to the doctor for approval. In some cases it may take up to TEN (10) days for records to be released.
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number:*

Area CodePhone Number
Patient Email:*
example@example.com
I hereby authorize the Aesthetic Associates Centre / Shatkin Dental Health to release the following identifiable health information:*
The Information will be used or disclosed for the following purpose:*
New Doctor's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Doctor's Phone Number:

Area CodePhone Number
New Doctor's Fax Number:

Area CodePhone Number
New Doctor's Email Address:
example@example.com
I would like my records to be sent by (please select all that apply):*

Email to my email addressEmail to my new doctor's email addressPost Mail to the patient's residancePost Mail to the new doctor's office
If you have ONLY been to the Aesthetic Associates Center or Shatkin Dental Health for a FREE Consultation a maximum fee of $299 may be required to obtain the CT scan or any xrays. Have you only been to the Aesthetic Associates Centre or Shatkin Dental Health for a FREE consultation?*

Yes, I have ONLY had a FREE consultationYes, I have ONLY had a single $43 cleaning at SDHNo, I'm a REGULAR PATIENT of the Aesthetic Associates Centre or Shatkin Dental Health
This authorization is valid for 90 days and may be revoked at any time in writing prior to the expiration date. Additional authorization for disclosure beyond the recipient is required.
Authorized Signature of Patient or Legal Guardian (WE CAN NOT PROCESS YOUR REQUEST WITHOUT A SIGNATURE):*

Clear
Should be Empty: