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PATIENT RECORDS ACCESS RELEASE FORM I, ___, hereby request a copy of my dental records. Please send them to the following address listed below. Savannah Dental Aesthetics Dr. Russell D. Clemons, DDS,
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How to fill out dental records release form
How to fill out dental records release form
01
Obtain a copy of the dental records release form from the dentist's office or website.
02
Fill out your personal information including your name, date of birth, address, and contact information.
03
Specify the dates of the records you want released and the reason for the request.
04
Sign and date the form to authorize the release of your dental records.
05
Make a copy of the completed form for your records before submitting it to the dentist's office.
Who needs dental records release form?
01
Patients who are transferring to a new dentist and want their previous dental records transferred.
02
Patients who are seeking a second opinion from another dentist.
03
Patients who are moving to a new location and need their dental records transferred to a new dentist.
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What is dental records release form?
The dental records release form is a document that allows individuals to authorize the release of their dental records to another party, such as a new dentist or insurance company.
Who is required to file dental records release form?
Anyone who wishes to transfer their dental records to a different dental provider or entity may be required to file a dental records release form.
How to fill out dental records release form?
To fill out a dental records release form, individuals typically need to provide their personal information, the information of the recipient, and sign the authorization to release their records.
What is the purpose of dental records release form?
The purpose of a dental records release form is to ensure that the patient's dental records are transferred securely and with proper authorization to protect their confidentiality.
What information must be reported on dental records release form?
The dental records release form may require information such as the patient's name, date of birth, dental provider information, and the reason for the records transfer.
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