Dental Records Release

This form only needs to be completed if you have had x-rays taken in another dental office in the last 5 years, if we need to obtain implant information, or if you would like us to send your x-rays to another dental office.
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the use or disclosure of the following individual’s health information as described below:
Name

First Name Last Name
Date of Birth

Month Day Year
Date of Birth
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What would you like us to do?
I HEREBY AUTHORIZE Type Previous Dental Office name here
TO RELEASE MY RECORDS TO CHCCW DENTAL
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
I HEREBY AUTHORIZE CHCCW DENTAL TO RELEASE MY RECORDS TO Type New Dental Office name here
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Please include the following:

Complete records (chart notes, perio charting, and x-rays) X-rays Other
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and resend my written revocation to the HIPPA Compliance Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law revokes my insurer with the right to contest a claim under my policy, unless otherwise revoked. I understand that authorizing this disclosure of health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect a copy of the information to be used or disclosed as provided in 45 CFR 164.524. I understand that any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected by federal confidentially rules. If I have any questions about the disclosure of health information I can contact the HIPPA Compliance Office at CHCCW. I understand there could be a fee associated with the reproduction of my medical records. I understand by signing this authorization I am required to pay for the reproduction of my medical records in advance, even in the event I decide to cancel my request. In accordance with HIPAA standards, CHCCW will not bill me for the retrieval of my medical records
The authorization will expire on the following date event or condition date of expiry .
If I fail to specify a date, this authorization will expire in twelve (12) months.
***PLEASE ALLOW UP TO TWO WEEKS FOR RECORDS TO BE SENT. ***
Signature of patient or Legal Representative:

Clear
If signed by Legal Representative:

First Name Last Name
Relationship to patient:
Should be Empty:

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION