Get the free Dental Referral Release Form - Tri-County Health Network
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DENTAL RECORDS RELEASE FORM 1436 N. Hancock Ave., Colorado Springs, CO 80903 Records@CommunityDentalHealth.org (719) 3103315 ___ Patients Full Name Date of Birth ___ Address, City, State and Zip Code
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How to fill out dental referral release form
How to fill out dental referral release form
01
Obtain the dental referral release form from the dentist or dental office.
02
Fill out the patient's personal information including full name, date of birth, and contact information.
03
Provide details of the referral, including the referring dentist's name, contact information, and reason for referral.
04
Sign and date the form, confirming that you acknowledge and authorize the release of your dental records.
05
Submit the completed form to the appropriate party as instructed by the dentist or dental office.
Who needs dental referral release form?
01
Individuals who have been referred to another dentist by their current dentist.
02
Dental specialists who require access to a patient's dental records for consultation or treatment purposes.
03
Dental insurance providers who need verification of a dental referral before approving coverage for specialized treatments.
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What is dental referral release form?
The dental referral release form is a document that allows a patient's dentist to refer them to another dental specialist for further treatment.
Who is required to file dental referral release form?
The patient's current dentist is required to fill out and file the dental referral release form.
How to fill out dental referral release form?
To fill out the dental referral release form, the dentist must provide the patient's information, the reason for the referral, and any relevant medical history.
What is the purpose of dental referral release form?
The purpose of the dental referral release form is to authorize the transfer of a patient's dental records and information to another dental specialist for continued treatment.
What information must be reported on dental referral release form?
The dental referral release form must include the patient's name, contact information, dental history, reason for referral, and any relevant medical conditions.
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