Records Release Form | Healthy Smiles Forever

Release of Patient Records

HSF Release 2023
Dental Clinic at Prestige Care, Maple Springs Palmer and Wasilla Anchorage and Valley Pioneer Home
Christian Health Associates, C/O: HSF

2121 Abbott Rd., #202 Anchorage, AK 99507

Phone: (907) 802 -1500

Email: hsf@christianhealth.org

Fax: (907) 522-7088 Attn: JoAnne Cummings
Patient’s Name
Date of Birth

MonthDayYear
Date
Today’s Date

MonthDayYear
I authorize Healthy Smiles Forever to forward records to:
Type Name Of the Institution
The following records may be forwarded to Healthy Smiles Forever

x-raystreatment recordsperiodontal records
Printed Name
Patient/Legal guardian Signature:

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Release of Patient Records