Release form

Online Release Authorization

* Indicates required field

Name *

First

Last

Date of Birth *

Email *

I give permission to release my records from: *

Previous provider name *

Previous provider phone number *

If you are requesting xrays being sent to another provider, please provide the email address to transfer records to. If one is not provided, there may be a delay. All emails are encrypted for confidentiality.

Email to send records *

I understand this authorization is voluntary, and I may refuse to sign this authorization. I have the right to request a copy of this form after I sign it. I may revoke this authorization at any time by notifying MJP Family Dental in writing. However, it will not affect any actions taken before the revocation was received or actions taken in reliance thereon. If the person or organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.

I Consent to information release *

Agree Disagree

Signature *

Submit