AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION TO:

Aimee M. Fujioka, DMD, PS
215 NW 78th St
Vancouver, WA 98665
Tel: 360.696.4439
Fax: 360.696.4455

Thank you! We have received your information.




I request and authorize the following health care provider to release health care information of the patient named above.



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

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 of patient or patient's authorized representative



Relationship or status if signed by anyone other than patient (parent or legal guardian)
2 + 2 =