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Riccobene Associates Family Dentistry 12330 Hwy 210 Suite 115 Benson, NC 27504 ×919) 207-2077 Authorization for Release of Dental Records and X-rays Date: I, (print patient or guardian name), hereby
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How to fill out records release formmcgees:
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Start by downloading the records release formmcgees from the official website or obtain a physical copy from the relevant authority.
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Begin filling out the form by providing your personal information such as your full name, date of birth, and contact details.
03
Next, indicate the specific records you would like to release by providing details such as the name of the healthcare provider or institution, the dates of treatment or service, and any other relevant information.
04
If you are authorizing the release of your records to another individual, make sure to include their full name, contact information, and their relationship to you.
05
Review the form thoroughly to ensure all the information provided is accurate and complete. Make any necessary corrections or additions before proceeding.
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Sign and date the form in the designated areas. If required, have any additional witnesses or notary public sign the form as well.
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Make a copy of the filled-out form for your records before submitting it to the appropriate authority or healthcare provider.
Who needs records release formmcgees:
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Patients who want to request their medical records from a healthcare provider or institution.
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Patients who are changing healthcare providers and want to ensure a smooth transition of their medical records.
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Individuals who wish to review their own medical history or obtain important medical information for personal purposes.
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