Fujioka Family Dentistry | Medical Release Form

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

Patient Name:*		Date of birth:*	Previous Name:
I request and authorize the following health care provider to release health care information of the patient named above.
Name (of health care provider):* Mailing address:* City/State/Zip:*
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:
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:*
Relationship: Relationship or status if signed by anyone other than patient (parent or legal guardian)

What's the sum of:* 2 + 2 =