I authorize the release of dental records from:


 

I authorize the release of my dental records to:
Practice: PARAGON DENTAL by JON ANDERSON DDS
Address: 4745 Boardwalk Drive, suite D102 | Fort Collins, CO 80525
Phone number: 970-552-7874 | Fax number: 970-480-9786
Email address:

The execution of this form does not authorize the release of information other than that specifically described below.

INFORMATION REQUESTED

DATES REQUESTED:


 

I hereby request and authorize the transfer of my protected dental health records, or the protected health records of the above listed individual for whom I am the patient/ a legal guardian. I understand this transfer request is to be honored for sixty (60) days from the date of this authorization. I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance of this consent. I understand the information disclosed, because of this authorization, may be further disclosed by the recipient.