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Dental Radiograph Release Form Name: DOB: Please release my dental radiographs to:drmitola2 NICAP.RR.consigned Date David Viola, DDS 70 Rem sen Street Cohos, NY 12047 5182370700 (p) 5182370725 (Fax)
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How to fill out please release my dental

01
Start by downloading the 'Please Release My Dental' form from the official website.
02
Fill out your personal details such as your name, address, and contact information in the designated fields.
03
Provide your dental insurance information, including the insurance company's name, policy number, and group number.
04
Specify the reason for requesting the dental release. This could be due to changing dentists, seeking a second opinion, or transferring your records to a different dental provider.
05
Sign and date the form to certify that the information provided is accurate.
06
If required, attach any supporting documents or dental records that may be necessary for the release process.
07
Double-check the form to ensure all fields are completed correctly and legibly.
08
Submit the filled-out form either in person at your dental office or via mail/email, following the instructions provided by your dental provider.

Who needs please release my dental?

01
Anyone who wishes to transfer their dental records to a new dentist or dental provider may need to fill out the 'Please Release My Dental' form.
02
This form can be used by individuals who are changing dentists, seeking second opinions, switching insurance providers, moving to a new location, or simply requesting their dental records for personal reference.
03
Patients who require specialized dental treatments from a specialist may also need to fill out this form to ensure their records are sent to the appropriate practitioner.
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Please release my dental is a form used to authorize the release of dental records or information to a specified individual or entity.
The patient or their legal guardian is typically required to file a please release my dental form.
To fill out please release my dental, you will need to provide your personal information, specify the recipient of the information, and sign and date the form.
The purpose of please release my dental is to allow the release of dental records or information to a specific party for various reasons such as treatment continuity or legal purposes.
The information required on please release my dental typically includes the patient's name, date of birth, contact information, the recipient of the information, and the reason for the release.
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