Release of Records

To Dental Health Services

Use the following form to grant a release to allow Dental Health Services to obtain your existing records.
Use the following form to request a Release of Records transfer from Dental Health Services.

Authorization to Release Records to Dental Health Services - Minnewaska, PLLC.
Date*
MM slash DD slash YYYY
Dental Provider / Clinic Name: (where records will be coming from)*
Dental Provider/Clinic Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Dental Provider/Clinic Phone*
Dental Provider/Clinic Email
Consent*
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, and request that they
be transferred to:
Dental Health Services, Minnewaska PLLC | Glenwood, MN 56334
Email: [email protected] | Fax: (320) 634-3567 | Phone (320)634-3556
Consent*
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.
Patient First and Last Name*
First Last
Patient Birthdate*
MM slash DD slash YYYY
Consent*
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

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