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Summary: UNIVERSITY OF MINNESOTA
Twin Cities Campus Boynton Health Service 410 Church Street S.E.
Minneapolis, MN 55455
Office for Student Affairs www.bhs.umn.edu
AUTHORIZATION FOR THE RELEASE OF DENTAL INFORMATION
I authorize Boynton Health Service to release to:
Address:
I authorize
Address:
to release to Boynton Health Service, 410 Church Street SE, Minneapolis, MN 55455
information regarding:
(what information, i.e. clinic notes, x-rays, etc.)
to be used for
(continuing care, completing a form, etc.)
PATIENT IDENTIFYING INFORMATION
Name (Please Print) Birthdate / /
Student ID #: Boynton Medical Record #:
Address:
Telephone - Home: ( ) Work: ( )
· I understand that I may revoke this authorization by written request at any time to the address
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