Get Aspen Dental Patient Authorization for Release of Health Records to External Parties
authorization to disclose the following information: All treatment information Information specifically related to these treatment dates Starting Date: End Date: I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no longer be used or released. I may revoke this authorization by notifying Aspen Dental in writing. Signature of Patient (or Patient Representative) Printed Name of Patient (or Patient Representative) Date .
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