Records Release Form | Healthy Smiles Forever

Request For Patient Records

HSF Request 2023 - If any area of the form is not applicable to you put NA in box.
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 (fill in name of institution in box below) to forward the following dental records to Healthy Smiles Forever:
Type Name Of the Institution
x-raystreatment recordsperiodontal records
Printed Name
Patient/Legal guardian Signature:
Should be Empty:

Request For Patient Records