Form

Authorization to Release Protected Health Information

Please note, a separate form is required for each patient.
All record transfer requests will be completed within 30 days, as required by the Texas State Board of Dental Examiners.

Patient Information

Patient First Name

Patient Last Name

Patient Date Of Birth

Phone

At my request, Children's Dentistry of North Dallas may release the following information:

Reason for Request:

Please Explain:

Entity or Person to Receive Protected Health Information:

Record transfers will be processed electronically. Records will be sent to the email address provided below.

Name

Address

City

Zip Code

Phone

This authorization shall remain in effect until the information has been forwarded as requested or until the course of treatment is complete.

Our office will complete the record transfer within 30 days of receipt of an authorized Release as required by the Texas State Board of Dental Examiners. Please contact our office at 214-378-8868 after completing this form if URGENT release is needed. Incomplete requests will not be honored.

Patient's Rights:

I have the right to revoke this authorization at any time.
I may inspect the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
I understand that released information may include communicable disease diagnosis, such as HIV.
I may refuse to sign this authorization and my treatment will not be conditioned on signing.

I understand that the requested protected health information will be sent via encrypted email to the email address provided above. I confirm that the email address provided is correct and release Children's Dentistry of North Dallas of any liability if I have provided an incorrect email address. Although the information will be sent in an encrypted manner, I understand that Children's Dentistry of North Dallas is not responsible for any misuse of the protected health information by the recipient. By signing below, I hereby request that Children's Dentistry of North Dallas release the protected health information of the patient named above to the Person or Entity listed on this form.

Authorized Signature (Parent/Legal Guardian or Patient if over 18 years old)

Today's Date

Full Name of Person Completing Form

Please upload valid parent/legal guardian photo ID or other document verifying authorization to request record release (Required).

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