Patient Records Request

EFFECTIVE 7/1/16 THERE IS A CHARGE OF $30 FOR RECORDS REQUESTS, UPON PAYMENT RECORDS WILL BE AVAILABLE WITHIN 7-10 BUSINESS DAYS.

There are many reasons why people may need copies of their dental records. Regardless of the reason, we would be more than happy to assist you. To protect your privacy and maintain the security of your personal records we will be doing a verification confirmation by phone or email.

 

The Texas Dental Board grants providers 30 days to provide records. We will gladly process and finalise ALL requests within 7-10 business days. NO EXCEPTIONS.  For more information regarding this policy on The Administrative Code for Records you may visit the STATE BOARD OF DENTAL EXAMINERS website.

 

To make your official request please complete this online form to authorize the records release.

Records Release Request

I hereby authorize release of dental records for my child.

Patient's Full Name*

 

Guardian's Signature*

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

 

Patient's DOB*

 

Email*

 

Phone*

 

Reason for Request*
What are you requesting?

 X-Ray Records Other

 

I understand that all information I hereby authorize to be obtained will be held strictly confidential and cannot be released without my written consent. I understand that this authorization will remain in effect until revoked by me in writing. I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by submitting my request in writing.
 

I understand that THIS POLICY IS IN ACCORDANCE WITH THE TEXAS STATE BOARD OF DENTAL EXAMINERS RULE 108.8 SUBCHAPTER A.
 

(g) A dentist shall furnish copies of dental records to a patient who requests his or her dental records. At the patient's option, the copies may be submitted to the patient directly or to another Texas dental licensee who will provide treatment to the patient. Requested copies, including radiographs, shall be furnished within 30 days of the date of the request. The copies may be withheld until copying costs have been paid. Records shall not be withheld based on a past due account for dental care or treatment previously rendered to the patient. Copies of dental records submitted in accordance with a request under this section shall be legible and all copies of dental x-rays shall be of diagnostic quality. Non-diagnostic quality copies of dental x-rays shall not fulfil the requirements of this section

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