Dental Records Release Form

PATIENT INFORMATION

Name

Date

AUTHORIZES

Radiant Dental of Bedford 902 Echo Vale Drive Bedford, PA 15522

I hereby authorize

To Pick up my records (Photo ID required)

SEND TO

Name of Health Care Provider / Plan / Other / Myself

Address

Phone No.

Fax No.

Email address

Only information from the past five (5) years will be disclosed. Unless dates filled in below.

FROM

When transferring information to another dental office we only send current x-rays (bitewing x-rays, full mouth x-rays & panorex) within the last 5 yrs and treatment dates for prophy’s (cleanings) – exams – scale & root planning.

If you want us to release other information then please mark below.

INFORMATION TO BE DISCLOSED

Treatment plan

Radiology films/images

All billing records

Specific records/information as follows:

I DO NOT WANT THE FOLLOWING INFORMATION DISCLOSED:

EXPIRATION: This Authorization is good for one year unless dates filled in below

FROM

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient / Legal Rep.

Date

If signed by a person other than the patient, complete the following:

Individual is:

parent/legal guardian legally incompetent

incapacitated deceased

next of kin/executor of deceased

By signing, I understand that the information released per this authorization, if redisclosed by the recipient, is no longer protected by Radiant Dental of Bedford.

Your information will be encrypted.