Rho Family Dentistry logo1
icon location at double resolution 2525 K Street, Suite 108 Sacramento, CA
Facebook
Yelp
Google


Patient Request for Release of Records
























Patient’s Full Name:
Patient’s Date of Birth:
Requested By: PATIENT
PARENT/LEGAL GUARDIAN
PERSONAL OR LEGAL REPRESENTATIVE OF THE PATIENT
Photo ID and other proof of representation may be required.
[Optional] If the requestor is NOT the patient, the following Requestor Information is REQUIRED:
Requestor’s Full Name:
Requestor’s Address:*
Requestor’s Telephone Number:*
Required Approval:* I HEREBY AUTHORIZE RHO FAMILY DENTISTRY TO RELEASE INFORMATION CONTAINED IN THE HEALTH RECORD OF THE PATIENT'S FULL NAME INDICATED ABOVE.
Required Approval:* PLEASE SEND REQUESTED RECORD VIA UNENCRYPTED EMAIL. I RECOGNIZE THAT EMAIL IS NOT A SECURE FORM OF COMMUNICATION. THERE IS SOME RISK THAT ANY INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION AND OTHER SENSITIVE OR CONFIDENTIAL INFORMATION THAT MAY BE CONTAINED IN SUCH EMAIL MAY BE MISDIRECTED/DISCLOSED TO/INTERCEPTED BY UNAUTHORIZED THIRD PARTIES.
Email address to where Rho Family Dentistry can send records:
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 the patient has specifically provided below [if none - please write “none”]
This authorization is effective now and will remain in effect until [insert date below]. I understand that I may receive a copy of this authorization.

Copyright © 2017-2022 Rho Family Dentistry and WEO Media (Touchpoint Communications LLC). All rights reserved.  Sitemap | Links
Rho Family Dentistry, 2525 K Street, Suite 108 Sacramento, CA 95816 • (916) 562-2755 • rhofamilydentistry.com • 11/30/2022 • Related Terms: dentist Sacramento CA •