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Record Release Form


 

Dental Records Release Form

I, ________________, am requesting copies of all my dental records. The duplicate records may be:

  1. Given to me directly
  2. Given to a representative in a seal protected envelope, or
  3. Sent directly to a dental office.

( 1 ) If I choose to pick up my dental records in person, I will need to pay a duplication fee before my dental records are copied (see below *). Once my fee is paid, the dental team will copy my records within 2 days. After 2 days, I may return to the office and obtain my records. Fees may be paid by cash, check, or charge.

( 2 ) If I send a representative to pick up my records, I will need to pay a duplication fee before my dental records are copied (see below *) Once my fee is paid, the dental team will copy my records within 2 days.After 2 days, my representative may return to the office and obtain my records. I understand that my name will not be on the sealed envelope, but my “chart file number” will be displayed. This is to protect my privacy as indicated by HIPPA. The name of my representative is ___________________ and their relationship to me is __________________. I understand and have discussed with my representative that they will need to show ID. Fees may be paid by cash, check, or charge.

( 3 ) If I choose to have my records mailed to another dental office or an address of my choosing, I will need to pay a duplication fee plus postage before my dental records are copied ( see below * ). Once my fee is paid, the dental team will copy my records within 2 days. After 2 days, your records will be mailed to the address you provide. The following address is where I want the records mailed: _______________________. Fees may be paid by cash, check, or charge.

Location
Celebrity Smiles
2575 W New Haven Avenue
West Melbourne, FL 32904
Phone: 321-209-7525
Fax: 321-821-4803
Office Hours

Get in touch

321-209-7525