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 reply to the email address that this was originally sent from. If it was sent via fax, you can instead email to: jasmine@purecaredental.com

Please be aware of "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