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Bates Dental, PS 2700 S Southeast Blvd, Suite 104 Spokane, WA 99223 Phone (509) 7955878 Fax (509)3834199 Dental Records Release Form Patient Name to Transfer: Date of Birth: Phone Number: Other Family

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How to fill out dental records release form

How to fill out a dental records release form:

01

Start by providing your personal information. Fill in your full name, date of birth, and contact information.

02

Indicate the purpose of the request. Specify whether you are requesting the dental records for your own personal use or if they need to be released to another healthcare provider.

03

Specify the dates of treatment. Provide the start and end dates of your dental treatment or specify a specific timeframe if applicable.

04

Provide the name and address of the dentist or dental clinic where the records are currently held.

05

State the reason for obtaining the dental records. It could be for review, transfer, or research purposes.

06

Sign and date the form at the bottom to acknowledge that you are authorizing the release of your dental records.

07

Make a copy of the completed form for your records before submitting it to the appropriate person or organization.

Who needs a dental records release form?

A dental records release form may be needed by various individuals or organizations, including:

01

Patients who wish to transfer their dental records to a new dentist or healthcare provider.

02

Healthcare providers who require a patient's dental records in order to provide appropriate treatment or to coordinate care.

03

Researchers who need access to dental records for scientific studies or medical advancements.

04

Insurance companies or legal professionals who may require dental records for claims or legal proceedings.

Overall, a dental records release form is essential for ensuring the appropriate transfer and access to dental records, while also maintaining patient privacy and confidentiality.

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What is dental records release form?

The dental records release form is a document that allows a patient to authorize the release of their dental records to another party.

Who is required to file dental records release form?

Any individual who wants their dental records to be released to another party is required to file the dental records release form.

How to fill out dental records release form?

To fill out the dental records release form, the patient must provide their personal information, the recipient's information, specify the time frame for the release, and sign the form to authorize the release.

What is the purpose of dental records release form?

The purpose of the dental records release form is to ensure that the patient's dental records are shared securely and only with authorized individuals or parties.

What information must be reported on dental records release form?

The dental records release form must include the patient's name, date of birth, contact information, the recipient's name and contact information, the purpose of the release, and the time frame for the release.

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