Please release or transfer the selected type of records for the above named patient to the following dental office or individual:
*There is a charge of $10.00 plus $1.00 per page up to 25 pages and $.25 for each additional page to have your records sent with this method
I understand that if information is not sent in an encrypted manor, there is a risk that it may be accessed by unauthorized parties. I still wish to have records send electronically via email.
This form is required for every release of records request. The request to release records will expire when the records have been released via your preferred collection method.
I understand by signing the Release of Records Request, I am terminating the Doctor/Patient relationship with Dr. Jodi Mason and Bean Tree Pediatric Dentistry. Patient will be deactivated with our practice on the day records are released to requesting party or authorized agent. Future care will need to be met by an alternate provider.