Release of Records Request Form

  • Records Release

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

    • 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.
  • 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.