Dental Records Release

Authorization for Release of Dental Records

I authorize PRDC staff to release medical or dental records on my behalf to the following entity/provider:

Patient's Name*

First NameLast Name

Date of Birth*

Date

Physician/Dentist/Provider’s Name*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Fax Number*

Email Address

Select level of authorized medical or dental records release:*

Please release a full copy of my dental/or medical recordsPlease release only the specific information requestedPlease release only the following information:

I understand that by signing below I am allowing my medical/dental records to be transferred from one office to another and that there is a chance that they may accidentally be released to someone other than those entities listed above. I understand that Piedmont Regional Dental Clinic may release my records/information by fax, email, or mail. I further acknowledge that this release is valid for one year unless otherwise noted below.

This is a one-time release of informationThis release is valid until the following date:

SIGNATURE OF PATIENT OR LEGAL GUARDIAN*