Greenfield, Salinas & La Ceyba Dental

Authorization for the Release of Dental Records

Please take a moment to fill out this form so we may release your dental records.

I hereby authorize Dr. Ernesto Mireles, Greenfield Salinas & La Ceyba Dental and its Staff to release the information in the dental record of:

Patient's Name

to:

Name of dentist, physician, clinic, or patient’s representative

Dentist/Physician/Clinic/Representative Address:

Type of format requested:

Dexis –do they need a sampler program?

Yes

JPEG Format?

Yes

Do you want this in a CD or email or printed in paper?:

Any and all information may be released including, but not limited to, mental health records protected by the Lanterman-Petris-Short act, drug and/or alcohol abuse records and/or HIV test results, if any, except as specifically provided below:

I understand and agree to pay a reasonable charge to cover the costs of the transfer, as allowed in Health and Safety Code ss123100 et seq. and Evidence Code s1158.)

This authorization is effective now and will remain in effect until the date below. I understand that I may receive a copy of this authorization.

Authorization expiration date

Patient's Signature:

Date:

If not signed by the patient please indicate relationship:

Parent or guardian of minor patient

Guardian or conservator of an incompetent patient

Beneficiary or personal representative of deceased patient

Note: to be valid, an authorization must be clearly separate from other language on a page and executed by a signature, which serves no purpose other than to execute the authorization. It can either be handwritten by the person who signs it or in typeface no smaller than 8 point.

$39.00- Duplicating fee for x-ray request/ $50.00 for chart copy request/ $50.00 for each copy of orthodontic records request.

Patient Validation:
Validacion del Paciente

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