Authorization to Release Dental Records

I authorize Jemima Poitevien, D.D.S., P.L.L.C, dba Children's Dental Haven, to release dental records for my child / children listed below

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Name

Address

City

State

Zip

Telephone No.

Fax

Email address

Electronic medical records are preferred

Any records provided via e-mail to another dental office will be sent securely to safeguard your protected health information.

You have the option to request records be sent to you so you can then forward them to another dental office as needed. These records will be sent securely through our encrypted e-mail. Secure e-mail protects your personal information from any unauthorized access. The confidentiality of regular e-mail cannot be guaranteed.

I request records be sent to me at

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.

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Date

Relationship to Patient

Authorization Expires One Year After It Is Signed

Your information will be encrypted.