Outgoing Records Request Form

Patient Information:

Please enter the name and date of birth for each patient wishing to transfer their medical records. If you wish to submit your information to more than one office, pleae submit this form for each office.

I authorize the release of my confidential protected dental information, as described in my
directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions.
The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected dental information