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   Release of Dental Records

    

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Release of Dental Records

Patient

Name: _________________________________ Patient ID: _________________________________
Phone: _________________________________ Email: _________________________________
Address: _________________________________

Transfer From

Original Dentist: _________________________________ Clinic: _________________________________
Fax: _________________________________ Email: _________________________________
Phone 1: _________________________________ Phone 2: _________________________________
Address: _________________________________

Transfer To

New Recipient: _________________________________ Clinic: _________________________________
Fax: _________________________________ Email: _________________________________
Phone 1: _________________________________ Phone 2: _________________________________
Address: _________________________________

Authorized Information to Disclose

Release of Dental Records

Exam/Treatment Notes
X-Rays
Treatment Plans
Other:___________________

Method of Transfer

Release of Dental Records

Fax
Email
U.S. Mail
Other:___________________

Reasons for Disclosure

Release of Dental Records

Legal Requirement
Insurance Claim or Dispute
New Dental Care Provider
Specialist Consultation
Second Opinion
Other:___________________

I, the patient, understand that I may revoke my consent, in writing, at any time. I understand that my information will be held in the strictest confidence and will be read, shared, and held by no parties other than those who transfer the information and those who receive it.

(Patient's Signature)

(Dentist's Signature)

(Date)

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