I request and authorize the above-named dental office or healthcare organization to release the information specified below to Aspen Springs Dental.
I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. This authorization is effective until such date that I choose to revoke it. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it.
A copy of this authorization may be used with the same effectiveness as the original.