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AUTHORIZATION TO RELEASE
DENTAL INFORMATION

The authorization of this form does NOT authorize the release of information other than the terms specifically described below.

I request and authorize the named doctor or health care provider to release the information specified 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:

*Limited to treatment dates and for

Purpose or need for which information is to be used: