Request for Release of Dental/Medical Records

Please note that it is important to fill in all the fields before submitting. Thank you.

Section A: Patient giving consent
*Name :
 *Last name

 Mid name

 *First name
*Home address :
CityState
ZipAPT#
*Email address :Social security# :
*Telephone Home : Cell phone# :


[honeypot country]

Section B: To the patient - please read the following statements carefully
Purpose of consent: By signing this form, you will consent to our use and disclosure of your protected health info. mation to carry out treatment, payment activities, and healthcare operations.
Notice of privacy practices: You have the right to read our Notice of privacy practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of out Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will issue a revised Notice of privacy practices. Which will contain the changes. Those changes may apply to any of your protected health information that we maintain.


Contact person :Email address :
Telephone Home: Fax # :
Address :
CityState
ZipAPT#
Right to revoke: you will have the right to revoke this consent at any time giving us written notice of your revocation submitted to the Contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.
Signature
I, , have had full opportunity to read and consider the contents of this consent form and your Notice of privacy practices. I understand that, by signing this consent form. I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
X I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers or demonstrations.


*Signature : Date:


If this consent is signed by a personal representative on behalf of the patient, complete the following:
Personal representative’s name
Relationship to patient


Verification:
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