Matix - Records Release Auth Form

Authorization for the Release of Dental Records
Patient Name *

First Name Last Name
Date

Month Day Year
Date
I hereby authorize Dr. First Name Last Name to release the information contained in my dental records to Madjid Matin, DMD, LLC.
Email to:

admin@chevychasedent al.com

I recognize that email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to, or intercepted by unauthorized third parties.

Mail to:

Madjid Matin, DMD
5530 Wisconsin Avenue, Suite #1110
Chevy Chase, MD 20815

Any and all information may be released including, but not limited to x-rays, photos, intraoral pictures, and clinical notes.
This authorization is effective now and will remain in effect until Date (date)
Signature *

Clear
Date

Month Day Year
Date
If not signed by the patient, please indicate relationship
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Authorization for the Release of Dental Records