Dental Records Transfer

Date

Name of Patient(s)

Date of Birth

Address

City

State

Zip

Email Address

Phone Number

Transfer Method

Please Select By Which Method

Mail

Pick Up

Please transfer the above named patient record(s) to

From Date

To Date

Legal Representative's Name (if applicable)

Relationship to Individual

Signature of Individual or Legal Representative

Records to Transfer

I would like the following records to be transferred and/or copied

X-Rays

Chart Notes

Patient Name Validation

Staff Member Initials

Important Information:

You have a right to have an answer to your request within 30 calendar days.
If the information is not at this location, you have a right to have an answer to your request within 60 days.
If there are delays in getting you the answer, you will be told of the delay.
The delay cannot be more than an additional 30 calendar days
You may be charged a fee.
Your request may be denied in certain limited circumstances.

I understand that the term "dental records" includes, but is not limited to, any and all reports, notes, doctor's and/or his employees' notes, clinical records, x-rays, charts, laboratory reports, test results, histories, diagnosis, opinions information obtained from other health care providers, and administrative information. I further understand that information obtained from other health care providers, and administrative information contained within my records may be protected by various federal and state privacy statutes. I further understand that Myers Pediatric Dentistry have no control over the release or distribution of requested dental records by those persons or entities to whom I have authorized copies of my records to be released.

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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