AUTHORIZATION TO RELEASE DENTAL RECORDS

I_______________________________________________________ authorize Ormond Beach Dental Group

to release my dental records to:

Name: ________________________________________________________________________________

Address:_______________________________________________________________________________

______________________________________________________________________________________

Phone: _________________________________________________________________________________

Patient Name : ___________________________________________________________________________

Signature of patient or legal guardian: ___________________________________________________________

Privacy Notice

The documents accompanying this message may contain information that is privleged,
proprietary, confidential or otherwise legally exempt from disclosure. This information
is intended only for the use of the individual or entity named above. The authorized
recipient of this information is prohibited from disclosing this information to any other
party and is required to protect the confidentiality of the information after its use has
been fulfilled.

If you are not the intended recipient, you are hereby notified that any retention,
disclosure, copying, distribution of action taken in reliance on the contents of these
documents is strictly prohibited. If you have received these documents in error, please
notify Paul Szott, DMD 386-671-6222 to arrange for their return or destroy all
copies of this message.