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
[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:
Authorization Approval:*	I HEREBY AUTHORIZE RHO FAMILY DENTISTRY TO RELEASE INFORMATION CONTAINED IN THE HEALTH RECORD OF THE PATIENT'S FULL NAME INDICATED ABOVE.
Email Security Acknowledgement:*	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"]
Release Exclusions:*
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.
Effective To Date:

By providing a mobile number, I agree that Rho Family Dentistry may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.