Requesting Patient Records

Patients 18 years of age are considered adults and therefore must request their own records.
Patient Name*
First Last
Reason for request*
- Collaboration of services with another specialist
- Returning to referring provider
- Personal use
- Appealing Insurance coverage denial
- Moving out of state
Type of Request*
- Radiographs only - No charge
- Photographs
- Services rendered
Method of records release*
- Email - Encrypted email will be sent to the email address on file in the dental chart with delivery notification.
- Mail - All records are mailed my certified mail and signature confirmation (additional charge of $10).
- In-person pickup.
Authorization for the Release of Protected Health Information
I understand that:*
- I have to allow a minimum of 3-5 business days for processing the request. *
- This authorization is only applicable for services provided upto this date. Any additional request for Release of Protected Health Information will require a separate 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.
- Submission of this form is my acknowlegement of consent and signature.
- I understand that there is a charge of $30 for the processing and preparation of patient records (unless only radiographs are requested). Please call our office once you have completed this form so that payment is processed and the records can be provided.
- I understand that only a parent or a legal guardian can request or consent to sharing patient records with another provider. *
Relationship to Patient*
- Mother
- Father
- Legal Guardian
Date*
Date Format: MM slash DD slash YYYY

Authorization for the Release of Protected Health Information