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RECORDS RELEASE REQUEST TO: ___ Address: ___ Phone: ___Fax: ___Email:I authorize the release of a hard copy of my dental treatment records and digital copies of all of my rays, including CT scans,
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How to fill out records release request to

01
Obtain a records release request form from the healthcare provider or facility.
02
Fill out all required information on the form, including your name, date of birth, and contact information.
03
Specify the records you want released and to whom they should be sent.
04
Sign and date the form, acknowledging that you authorize the release of your medical records.
05
Submit the completed form to the healthcare provider or facility either in person, by mail, or through their online portal.

Who needs records release request to?

01
Patients who want to request a copy of their medical records.
02
Legal representatives or family members authorized by the patient to request medical records on their behalf.
03
Insurance companies or other healthcare providers who require medical records for treatment or billing purposes.
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Records release request is a formal document requesting the release of specific records or information.
Anyone looking to access certain records or information is required to file a records release request.
To fill out a records release request, provide your contact information, specify the records you are requesting, and include any relevant details or reasons for the request.
The purpose of a records release request is to obtain access to specific records or information that are otherwise restricted or confidential.
The records release request must include the requester's name, contact information, the specific records being requested, and any relevant details or reasons for the request.
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