HIPAA Release Records Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Date today
-
Month
-
Day
Year
Date
Date From
-
Month
-
Day
Year
Date
Date To
-
Month
-
Day
Year
Date
Email (or address) you would like records sent to:
Records will be emailed for free. $50 fee would apply to print and mail records.
Person you wish us to send records to
Prefix
First Name
Last Name
Suffix
Type of Medical Information to be disclosed
All Dental Records
Financial Records
Xrays
Progress Notes
Other Information allowed to be disclosed
I give consent to the release of information pertaining to dental health records and/or treatment.
Back
Next
Signature of Patient / Subject
Clear
Date Signed
-
Month
-
Day
Year
Date
Submit
Back
Next
Parent or Legally Authorized Representative
In case the subject is beyond the legal age of consent:
Name of Parent or Guardian
First Name
Last Name
Relationship to Subject
Signature of Parent / Guardian
Clear
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty:
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