Get Authorization Form - Immediadent

Completing the Authorization Form - ImmediaDent online is a straightforward process that allows users to grant permission for their dental records to be shared. This guide provides clear, step-by-step instructions to help users navigate the form efficiently.

Follow the steps to successfully complete the Authorization Form.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the patient information section, which includes the patient's last name, first name, middle initial, street address, apartment number (if applicable), city, state, home phone, mobile phone, and zip code. Make sure all details are accurate to avoid any processing delays.
3. Next, input the patient's date of birth. This information is crucial for identifying the correct dental records.
4. Review the authorization statement that grants ImmediaDent permission to release information contained in the dental record. Ensure you understand the conditions under which you can revoke this authorization.
5. Specify the information requested, and be as clear and specific as possible, including the date of service if you know it. This helps in ensuring you receive the exact information needed.
6. If there are any restrictions or exclusions to the information you wish to share, make sure to indicate these in the provided section.
7. In the information released section, enter the name, telephone number, street address, suite/room, city, state, and zip code of the party you are authorizing to receive the information.
8. Finally, if the patient is 18 years of age or older, they should sign and date the form. If the patient is a minor, a parent or guardian should provide their signature, along with their relationship to the patient.
9. Review the entire form for accuracy, and once completed, you can save your changes, download, print, or share the form as required.

Complete your Authorization Form - ImmediaDent online today for a seamless experience.