Authorization to Release Medical Information

In some cases, you may want or need to share your dental records with another provider, specialist, or family member. To do this, we must have your written consent on file. Please complete the secure form below to authorize the release of your dental records to a designated individual or office.

This form ensures that your protected health information is released under HIPAA regulations and only to those you specifically authorize.

What you’ll need:

• The name and contact information of the person or provider authorized to receive your records
• Your personal identification details
• Your signature and date of authorization

This form is secure and HIPAA-compliant. We take your privacy seriously and will only release information as directed in this document.

If you have questions about this form or need assistance, please contact our office at Stewart P. Wignall DDS Office Phone Number (919) 942-8880.

Thank you for helping us protect your privacy while ensuring coordinated care through Stewart P. Wignall, DDS, PA.