Release of Records Request Form

Release of Records Request

Todays Date:

Patient Name:

Parent or Legal Guardian Name:

Relationship to Patient:

Address

Please release or transfer the selected type of records for the above named patient to the following dental office or individual:

How would you like to receive your records:

Certified Mail*

*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.

Most Recent Visit (Chart Notes, Clinical Findings & Radiographs)

All Radiographs (x-ray)

All Patient Data (Contains all Clinical Information for all Visits)

Practice Name or Name of Person:

Practice Email or Email of Person:

Address of Practice or Person

Phone Number of Practice or Person

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Your Rights (optional)

I understand that I have the right to revoke this authorization, in writing and at any time, except where uses or disclosures have already been made based upon my original permission. I might not be able to revoke this authorization if its purpose was to obtain insurance.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy
Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create Medical Records for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Additional Information (optional)

You have a right to have an answer to your request within 30 calendar days.
If there are delays in getting you the answer, you will be told of the delay.
The delay cannot be more than an additional 30 calendar days.
You may be charged a fee.
Your request may be denied in certain limited circumstances.

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.

Parent or Legal Guardian Signature:

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law

Release of Records Request Form

Release of Records Request

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