Comprehensive Dental Center

5908 Berryhill Rd.
Milton, Fl. 32570
(850) 623-0137
Dental Information Release Form
(Hipaa Release Form)

Name :
Date :

Release of Information

I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be release to :
Spouse :
Child (ren) :
Other :
Information is not to be released to anyone.

This release information will remain in effect until terminated by me in writing.


Please call
my home :
my work :
my cell :
The best time to reach me is (day) or (evening)
between (time)
If unable to reach me :
You may leave a detailed message
Please leave a message asking me to return your call.
Email using :
Signed :
Date :
Witness :
Date :