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DENTAL RECORDS RELEASE FORM PATIENT INFORMATION: Name: ___ Date of Birth: ___ AUTHORIZES: The Smile Zone 576 Sand Creek Road Albany, New York 12205 TO DISCLOSE TO: 1Self 1 Dental Provider 1 Other
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How to fill out authorization to transfer dental
How to fill out authorization to transfer dental
01
Fill out patient's personal information, including name, date of birth, and address.
02
Include details of the dental procedure being transferred.
03
Sign and date the authorization form to give consent for the transfer.
Who needs authorization to transfer dental?
01
Patients who are transferring their dental records to a new dentist.
02
Dental offices or providers who are receiving the transferred records.
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What is authorization to transfer dental?
Authorization to transfer dental is a form that allows the transfer of dental records from one dental provider to another.
Who is required to file authorization to transfer dental?
Any dental provider who is transferring dental records to another provider is required to file authorization to transfer dental.
How to fill out authorization to transfer dental?
Authorization to transfer dental can be filled out by providing patient information, reason for transfer, and signatures from both the sending and receiving providers.
What is the purpose of authorization to transfer dental?
The purpose of authorization to transfer dental is to ensure the smooth transfer of dental records between providers while maintaining patient confidentiality.
What information must be reported on authorization to transfer dental?
Information such as patient name, date of birth, reason for transfer, dental procedures performed, and any other relevant details must be reported on authorization to transfer dental.
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