Next Generation Dental
Request for Release of Records
5 W 71st St, Manhattan, NY 10023212-362-3360 · info@nxdental.com
Patient name
Date of birth
Phone
Email
Address
Previous name, if different
Records to release
- Complete dental record
- X-rays and images
- Treatment plan and chart notes
- Periodontal (gum) charting
- Billing and payment records
- Other (describe below)
Other records, or dates of treatment
Send the records to
- Me, the patient
- Another dentist or healthcare provider
- Another person or organization
Name
Phone
Address
Email or fax
How to send them
- Email (electronic copy)
- I will collect them from the office
Purpose
- Continuing care with another provider
- Insurance
- Personal use (my own copy)
- Other
Your rights
- This authorization ends on the date or event you write below. If you leave it blank, it ends one year after the date you sign.
- You may cancel this authorization at any time by writing to Next Generation Dental. Cancelling it does not affect records we have already released.
- Your treatment, payment and eligibility for benefits do not depend on whether you sign this form.
- Once records are released, the person or organization that receives them may share them again, and they may no longer be protected by federal privacy law.
- You are entitled to a copy of this signed form. We may charge a reasonable, cost-based fee for copies of records, as the law allows.
This authorization ends on (date or event)
Printed name, and relationship to the patient if signing for them
Patient, parent or guardian signature
Date