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S M I L E D E S I G N! E L L S W O R T H!AAR O NP A L M E R, D M D! Dental Records Release Form! Patient Name to Transfer: DOB: Practice Name: Address: City/ State/ Zip: Phone Number: fax: ! Transfer
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How to fill out smile desgn records release

01
To fill out a Smile Design Records Release form, follow these steps:
02
Start by downloading the form from the designated website or obtaining a physical copy from a dental office.
03
Fill in your personal information, including your full name, date of birth, and contact details.
04
Provide details about your dental treatment, such as the name of your dentist or orthodontist and the date of your last visit.
05
Indicate the specific records you are requesting, whether it includes X-rays, photos, or other dental documentation.
06
Read the release statement carefully and understand the implications of authorizing the disclosure of your dental records.
07
Sign and date the form to confirm your consent and acceptance of the terms.
08
Make a copy of the completed form for your records.
09
Submit the form to the relevant dental office or healthcare provider either in person or by mail, depending on their specified procedure.
10
It is advisable to follow up with the dental office to ensure that your records release request has been processed.

Who needs smile desgn records release?

01
Several individuals may need a Smile Design Records Release, including:
02
- Patients who are changing dentists and want to transfer their dental records to a new dental office.
03
- Individuals seeking a second opinion or seeking specialized dental treatment from a different dental professional.
04
- Patients involved in legal matters or insurance claims that require the release of dental records for documentation purposes.
05
- Individuals participating in dental research studies where the sharing of dental records is necessary.
06
- Those who want to maintain a personal copy of their dental records for their own reference and future dental care.
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Smile Design Records Release is a document that allows patients to authorize the release of their dental records related to smile design treatments.
Patients undergoing smile design treatments are required to file the Smile Design Records Release.
To fill out the Smile Design Records Release, a patient should provide personal details, specify the records to be released, and sign the document to grant authorization.
The purpose of the Smile Design Records Release is to obtain patient consent for the sharing of their dental records with other dental professionals or institutions.
The information that must be reported includes the patient's name, contact details, dental records to be released, and the recipient of the records.
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