Authorization To Release Dental Records

I, the below named patient, request the dental records as noted to be Released To:
Plage Dentistry
Dr. Robert Plage, Dr. Michael Plage
1802 New Hanover Medical Park Drive, Wilmington, NC 28403

Consent(Required)

This form permits Plage Dentistry to use and/or release the patient's health information for the purpose(s) described below.

Name(Required)

First Last

Main Contact Number(Required)

Date of Birth(Required)

Main Contact Number(Required)

Home Number

Cell Number

Work Number

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

RECEIPIENTS

Dentist office you are requesting records from

Consent

This practice may use and/or release the information check below to the following person or entity for the purpose(s) listed on this form.

Name(Required)

First

Office records are being released to.

Phone(Required)

Contact Person/Department

Name

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

CHECK THE TYPE(S) OF INFORMATION TO BE USED AND/OR RELEASED:

*If this request is for psychotherapy notes, any other records must be requested on a separate form. (No other boxes should be checked)

Entire record

Billing/insurance records

Office visit notes

Psychotherapy notes*

Lab/diagnostic results

Records specific to a certain condition/treatment

Clinical images (e.g., X-ray)

Other

Photos & Multimedia:

In office

On website

Photo taken by staff (e.g., pre/post procedure)

Photo received from patient or personal representative

Do Not Include:

Mental health records (Rx, diagnosis, etc.)

Communicable diseases (e.g., HIV/AIDS)

Alcohol/drug abuse treatment

Format/Delivery (if released)(Required)

Paper/mail

Email

USB/CD-ROM

Secure Portal

Fax

Other

Requests for information to be released to third parties must be sent in a secure manner.

PURPOSE FOR THE USE OR RELEASE

Please describe below:

This information will be used for marketing or fundraising activities. The practice/recipient will receive direct or indirect payment.

This practice will receive direct or indirect payment that is more than the usual fee charged to prepare and release the information (e.g., a sale of PHI).

Other

EXPIRATION DATE OR EVENT

(Not required if this authorization was started by the patient)

One-time use/release of information

Release this information until the end of a treatment or other event (e.g., physical therapy)

Other

PATIENT RIGHTS & SIGNATURE

*You can end this authorization at any time in writing. See our Notice of Privacy Pratices for exceptions. A termination will not apply to any releases of information that happen before we receive a written termination from you. *The recipient of the information could use or release it in a way that federal or state laws do not protect. This practice is not responsible for the privacy or security of your health information after it is sent to those listed on this authorization. *You can review or copy the information that will be used or released as described in this authorization. *You do not have to sign this authorization to receive treatment from this practice. *You understand that the information that will be used or released might include a communicable disease diagnosis such as HIV or a diagnosis related to mental health or substance abuse unless you exclude it above. *All changes or updates to this form mush be made in writing and signed by you (patient) or your personal representative. Minor edits (e.g., new phone number) can be made on this form, inititaled, and dated instead of requiring new form.

Signature

Date

38917

If you prefer to print and fill out form you can do so here.

Contact Us

Feel free to contact our office with any questions. We look forward to making each visit to our office a positive experience.