Release of Records

From Dental Health Services

Use the following form to grant a release of records from Dental Health Services to send you records to externally.

Authorization for Release of Dental X-rays from Dental Health Services - Minnewaska, PLLC
Date * Required
MM slash DD slash YYYY
Patient First and Last Name * Required
First Last
Patient Birthdate * Required
MM slash DD slash YYYY
Dental Provider/Clinic Name (where you want your records sent) * Required
Dental Provider/Clinic Address (where you want your records sent): * Required
Street Address City State / Province / Region ZIP / Postal Code
Dental Provider/Clinic Phone * Required
Dental Provider/Clinic Email
Consent * Required
I authorize the release of dental records and x-rays relevant to dental treatment.
I authorize the release of dental records and x-rays relevant to dental treatment. I am signing this form voluntarily and authorize to disclose my health information as described in this form.
Consent * Required
I agree my signature on this document is as valid as if I signed the document in writing.
This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.
Consent * Required
I agree and understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
Signature

Release of Records

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