Download Dental Records Release Form

Mattson-Hellickson Dental
Samuel J Mattson, DDS – James C Mattson, DMD
Benjamin B. Hellickson, DDS
Release of Verbal Medical/Dental Information
Patient Name:
Date:
Due to patient confidentiality laws, Mattson-Hellickson Dental does not release any
information verbally regarding our patients, except directly to the patient.
At times, patients may wish to have information on their medical or dental
treatment(s), condition(s), lab reports, medications, appointment times, billing
questions, etc. discussed with other individuals such as family members or
caretakers. Please indicate below any persons with whom you allow us to share
information regarding your condition, and their relationship to you.
EITHER:
I allow Mattson-Hellickson Dental to verbally release any information on my
medical condition(s), lab work, medications, appointment times, billing questions
and other medical information to the following person(s):
Person
Relationship
Signature:
OR:
I specifically forbid Mattson-Hellickson Dental to verbally discuss any aspect of my
medical or dental condition but anyone but myself.
Signature: