Release of Dental Records

Smiles on Trindle Dental Care

Please correct the errors described below.

I understand that:

  1. This authorization is voluntary and I may refuse to sign this authorization without affecting my dental care of the payment of my dental care.
  2. I have the right to request a copy of this form after I sign it, as well as, inspect or copy any information to be used and/or disclosed under this authorization.
  3. I may revoke this authorization at any time by notifying Smile on Trindle Dental Care in writing. However, it will not affect any actions taken before the revocation was received or actions taken in reliance thereon.
  4. If the person or organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
  5. Upon request I will be given a copy of my records. The orginal record remains the property of Smiles on Trindle Dental Care, and will be maintained by the office in accordance with Pennsylvania state laws.

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

Your information will be encrypted.

Loading...