Form

Authorization for the Release of Records

Office Name

Office Phone Number:

Office Fax or Email:

Patient Name:

Patient's Date of Birth:

PureCare Dental is requesting the following dental records:

Full Mouth Radiograph or Pano within the last five years
Bitewing radiographs within the last twelve months
If applicable; dates of service for scaling and root planning done at your office

Please email to velvet@purecaredental.com , or you may reply to the email address that this was originally sent from.

We would like to share with your office about "Right of Access" under the HIPAA Privacy Rule, which has not required a record release to another health care provider since 2013. Requiring a release to send electronic records is considered "information blocking" and is against federal law. You can find more information on the HHS.Gov website.

Patient or Legal Guardian Signature

Date