Requesting Patient Records | Pediatric Dentist - Reston, VA

Patients 18 years of age are considered adults and therefore must request their own records.

Patient (Child's) Name*

First Last

Person requesting the records for above patient*

First Last

Relationship to Patient*

Mother
Father
Legal Guardian

If the person requesting records is anyone other that mother or father, please submit credentials to info@smilewonders.com after completing this form. Thank you!

Email

Phone*

Reason for request*

Collaboration of services with another specialist
Appealing Insurance coverage denial
Moving out of state
Personal use
Other

Provide Other Reason*

Type of Request*

Radiographs only (for upto past 3 years) - No charge
List of services rendered (for upto past 3 years) - No charge
Intra-oral photographs - Processed for medical relevance as per findings - $30
Detailed visit report and findings - please provide a specific date of service - $30
Complete chart details of clinical findings, services recommended, services rendered and supporting documents including documents submitted by either parents, referring providers or other specialists - $175

Please list specific date of visit as applicable

Method of records release*

Email - Encrypted email will be sent to the email address on file in the dental chart with delivery notification.
Email - Encrypted email of the records to another dental office or service provider. Please provide email below.
Printed - In person pick - up.
Printed - Mailed via USPS to address on file unless details provided below. This is the LEAST PREFERRED method of releasing the dental records. If this route is absolutely necessary, we require that the records be mailed with signature confirmation upon delivery. There is an additional processing charge of $15.

Authorization for the Release of Protected Health Information

Please allow 3-5 business days for processing your request after payment is completed.

Only a parent or a legal guardian can request or consent to sharing of patient records.

This authorization is only applicable for services selected above and only for the spedific dates or time frames selected above. Any additional request for release of protected health information will require a spearate authorization.

Authorizing the disclosure of this healthcare information is voluntary. Once the information has been released according to the terms of this authorization, the information cannot be recalled.

Do you acknowledge that you have read, understand and agree to the information above?*

Yes

Total Charges*

Please add the amounts from fees listed in 'type of request' and 'method of records release' sections

Today's Date*

Signature