This document is an authorization form for Winn Family Dentistry to release a patient's health information. It allows the dental office to disclose x-rays and chart notes relating to the patient's treatment to any person or entity upon legal request or referral. The purpose is for continuity of care, further dental care, or legal proceedings. The patient signature acknowledges they understand and voluntarily sign the form, and can revoke authorization at any time except if the office has already acted upon it.

1. 2849 County Highway I
Chippewa Falls, WI 54729
(715) 723-0287 7
facebook.com/winnfamilydentistry
WINN FAMILY DENTISTRY, LLC
AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION
Per the office of Daniel J. Winn, D.D.S.
Patient Name:
Patient Address:
Patient Number:
Patient Cell Phone:
I authorize Winn Family Dentistry, LLC to release my health information, including but not limited to: information about HIV infection or AIDS, information
about substance abuse treatment, and information about mental health services under the following terms and conditions:
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.
You have the right to revoke your authorization at any time. The only exception to your right to revoke is if we have already acted in reliance upon the
authorization.
If you are signing as a personal representative of the patient or are giving consent to disclose any treatment information for your personal care, please
describe your relationship to the patient and/or source of your authority to sign this form:
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS
DESCRIBED IN THIS FORM.
Detailed description of the information to be released: X-rays and chart notes relating to patient treatment.
To whom may the information be released: To any person, business or entity upon receipt of a legal request form signed by above patient or
their legal representative or upon referral to a specialist by the treating Dentist.
The purpose(s) for the release at the request of the individual: Continuity of care, further dental care or for legal proceedings.
This release will stand indefinitely or until relationship is terminated by above patient or dental office.
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Relationship to Patient Patient Name (Print)
Patient Signature