Submit this form by providing the required information, signing, and dating it. Email the completed form to info@atkinsondentalhealthcenter.com or fax it to (603) 362-8410. You can also send it via mail to Atkinson Dental Health Center, 12 Main Street, Atkinson, NH 03811. Ensure all information is accurate and included for timely processing.

There are no specific important dates for this form in 2024 and 2025. The form can be used whenever authorization for dental record release is needed.

The purpose of the Dental Records Release Form is to authorize the transfer and release of dental records from one dental practice to another. This is crucial for continuity of care, allowing new dentists to review patients' previous dental history. The form also facilitates legal and insurance processes by providing an official record of dental treatments.

• 1. Patient or Guardian Name: Enter the full name of the patient or their legal guardian.
• 2. Date of Birth: Provide the date of birth of the patient or family members for identification.
• 3. Dental Practice Name: Input the name of the dental practice releasing the records.
• 4. Record Release Options: Check the appropriate boxes to specify the records to be released, such as x-rays or treatment records.
• 5. Contact Information: Include the address, phone number, and email of both the dental practice and the recipient.
• 6. Signature and Date: Sign and date the form to authorize the release of the records.

Failure to submit this form may result in delays or denial of the transfer of dental records. Without proper authorization, dental practices cannot legally release records.

• Delay in Dental Care: Delays in obtaining your dental records may impact the continuity of your dental care.
• Legal Implications: Non-submission may result in legal complications if records are needed for legal proceedings.
• Insurance Claims: Insurance claims may be delayed or denied if required dental records are not released in a timely manner.

• 1. Switching Dentists: When transferring your dental care to a new dentist, use this form to transfer your records.
• 2. Legal Requests: For legal purposes, such as lawsuits or court cases, requiring access to dental records.
• 3. Insurance Claims: When an insurance company needs your dental records for claim processing.
• 4. Family Records: For obtaining records of other family members under your care.
• 5. Medical Procedures: Use to transfer dental information to medical providers for related procedures.