Medical Release Form | Fujioka Family Dentistry

AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION TO:

Fujioka Family Dentistry
215 NW 78th St
Vancouver, WA 98665
360-696-4439
Patient Name:*
Name
Date of birth:*
MM slash DD slash YYYY
Previous Name:
Name
Name (of health care provider):*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone #:
Fax #:
The request and authorization applies to health care information relating to the following treatment, condition or dates of treatment (check all that apply):
- All health care information
- Chart notes only
- X-rays only
- Accounting records only
- Other
If other please specify:
Acknowledgement:
I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV/AIDS, sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use.
Signature:*

Signature of patient or patient's authorized representative.
Date*
MM slash DD slash YYYY
Relationship:

Relationship or status if signed by anyone other than patient (parent or legal guardian).
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Fujioka Family Dentistry