At the request of the individual, Center for Oral Health is authorized to disclose Dental Records to Self Dental Provider Center for Oral Health (Tampa Clinic)

All release forms must have a copy of the parent/guardians’ photo ID attached or records will not be released. Please ensure that picture of identification documents are clear and easy to read. Please allow two business days for the records to be available.

Authorization and Signature: I authorize the release of my confidential protected dental information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions.

[ ] I authorize the release of information including the diagnosis, records & examination rendered to me and claims information. This information may be released to: [ ] Spouse: ______________________________ [ ] Child(ren): ___________________________ [ ] Other: ________________________________ [ ] Information is not to be released to anyone.

State law generally determines who has the right to grant permission to release medical record information on behalf of a patient. That authority is generally granted to: A personal representative or the patient, such as a legal guardian or parent if the patient is incompetent or a minor child.

Authorization for Release of Information [ ] I authorize the release of information including the entire contents of dental record, including diagnosis, treatment details and financial information. This information may be released to: [ ] Spouse_____ [ ] Children_____

statement and consent to the release of medical/dental record for the purpose and extent stated above. INSTRUCTIONS: Please sign, then facsimile along with a copy of driver’s license to (407) 770 0171

All release forms must have a copy of the parent/guardians’ photo ID attached or records will not be released. Please ensure that picture of identification documents are clear and easy to read.

All release forms must have a copy of the parent/guardians’ photo ID attached or records will not be released. Please ensure that picture of identification documents are clear and easy to read. Please choose the Coastal Kids location of your most recent visit *