Dental Release Form – In order to serve you better, we ask for your permission to release your previous dental records. Please download and sign or print the form here:
By law, our office follows a written policy to protect our privacy that we create, receive or handle. Your responses are for our records only and will remain confidential in accordance with applicable law. Please note that you will be asked questions based on your answers to the attached questionnaire and there may be other questions about your health. This is important so that we can provide you with good care. This office does not use this information for discriminatory purposes.
Dental Release Form
If a child is not accompanied by a parent or legal guardian during treatment, we ask that you bring them to our office. This additional information will assist with support if it can be provided with permission but is not required.
Ortho Release Form: Fill Out & Sign Online
This notice explains how your health information may be used and disclosed and how you can access that information. Please review it carefully. Your health privacy is important to us.
Buehler Family Dental now offers affordable home dental care plans. Our plan includes dental care coverage and discounts on future plans.
“Dr. Buehler and his staff really understand their patients. They have the latest technology that makes me feel that my family is in good hands. His team is very professional and great to talk to.”
“The staff is great, they seem to work well as a team and talk you through everything step by step. For someone who doesn’t like going to the dentist, they made it fun!”
Dental Record Release Form Template
“Great professional office, Dr. Buehler and his entire team make me so happy, I don’t hate going to the dentist anymore. Thank you guys!!”
© Copyright, Buehler Family Dental, All Rights Reserved. Our office is diligent in following the latest health and safety standards. The Dental Record Release Form is a document provided by the dental patient or the patient’s parent or guardian if they are minors.
A short version of the medical discharge form is used to obtain dental reports from different doctors. The information is necessary for the dentist to review the records, so they are approved to proceed with treatment and care related to the patient’s needs. The patient or parent of the minor should assist the current dental professional in obtaining information.
Professionals mainly use dental reports to confirm when they have information about the patient’s oral changes. In addition, the document should also allow another doctor to better understand the patient’s condition and the concept of any given consideration.
Work Release Form
The dentist must choose the appropriate period of time to keep the reports, considering the records of adult patients must be available for ten years after the last date of treatment.
Note that this is a standard form, and other templates are available, such as the Dental X-ray Form.
If you are having trouble filling out the Dental Records Release form, use the tips below to ensure the best results:
2. Complete the patient information section. Enter full name and date of birth in correct order.
Free Medical Records Release Authorization Forms (hipaa)
3. The next section is called “Authorization.” On the next line, write the dentist’s name. Check all the appropriate boxes, and specify which documents should be moved. Specify whether the patient will collect the records in person or have someone else retrieve them (indicate who will be responsible for sending the records, using a photo ID).
If the document is to be mailed, enter the recipient’s name and address, phone number, email address, and fax number. The data will be stored in the dental department for five years unless you specify in a special way “from” and “to.”
4. Declaration of additional data is another field that must be filled. Check the box in this section with the information the patient chooses to disclose. Don’t forget to fill in the appropriate fields. If there is something the patient does not want the previous doctor or dental practice to know, state it.
5. Termination of employment. Unless otherwise stated in the lines provided, the authorization is valid for one year after signing the document. If the patient wants to extend the time, he can write about it in the lines provided.
Free Dental Records Release Form (hipaa)
6. Finally, sign the document. Complete the signature section of the patient or other authorized representative. Then date the signature in the right way. If someone (not the patient) is signing the document, check the appropriate box to indicate the person’s relationship to the patient. The patient must carefully read the last printed statement and write the full name of the dental professional who will issue the previous statement.
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