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  • AUTHORIZATION TO RELEASE DENTAL/HEALTH CARE INFORMATION TO CHANDLER FAMILY DENTISTRY

  • I request and authorize the doctor listed below and practice to release dental/health care records on the following patient to Chandler Family Dentistry/Dr. lrina Chandler, DDS, 253 Main Street, Warsaw, Virginia 22572, 804-333-0226.

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  • I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know canceling this authorization would not prohibit any release of information by the doctor or practice relying on my original authorization.

    There are two ways to cancel this agreement:

    • Sign and date a form available from the Doctor or Practice called “Revocation of Authorization for Use and Disclosure of Health Care Information.”
    • Write a letter to the Doctor or Practice. If I write a letter, it must say that I want to cancel my authorization to disclose my Health Care Information. I (or my authorized representative) must sign and date the letter.

    Once my doctor gives out the information I want to release, I know that my doctor has no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or state privacy laws may no longer protect the information.

    Please acknowledge by signing below.

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