Records Release Form

Records Release Request

Records Release Request

I hereby authorize release of dental records for my child.

Dental records requested

If the following field is left blank the records requested will be mailed to the patients home address we have on file.

Please complete a form for each child. Allow two weeks for processing.

I understand that my name entered in the box above stands for my signature and authorizes the release of my childs records.

Massachusetts General Laws Chapter 112, section 12CC and Board Regulation 234 CMR 2.04 require dental practioners to provide copies (not the originals) of patients records upon written request at a reasonable duplicating fee. The cost of this duplication is $25.00

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