Requesting Patient Records

Patient (Child's) Name

Person requesting the records for above patient

Relationship to Patient

MotherFatherLegal GuardianOther

If the person requesting records is anyone other that mother or father, please submit credentials to info@smilewonders.com after completing this form. Thank you!

Email on file

Phone

Type of Request X-rays only - No charge List of clinical services completed - No charge Intraoral Photographs - Processed for medical relevance as per findings - $30 Clinical visit report and findings - $30 Authorized counselors requesting complete records related to non clinical reasons - $175

Reason for request Collaboration of services with a specialist to facilitate laser frenectomy treatment (Lactation, Feeding, Speech, Sleep) Collaboration of services with a specialist orthodontic treatment IV sedation records for referring provider Post laser frenectomy note for referring/collaborating provider Records transfer to dental homeOther

Method of records release Email - Encrypted email will be sent to the email address on file in the dental chart with delivery notification. Email - Encrypted email of the records to another dental office or service provider. Please provide email below. Printed - In person pick - up. Printed - Mailed via USPS to address on file unless details provided below. This is the LEAST PREFERRED method of releasing the dental records. If this route is absolutely necessary, we require that the records be mailed with signature confirmation upon delivery. There is an additional processing charge of $15.

Encrypted emails cannot be forwarded. Please provide any additional emails so that we can send records directly to each address.

Total Charges related to above selections.

Please add the amounts from fees listed in 'type of request' and 'method of records release' sections. If applicable, a payment link will be sent to you.

Authorization for the Release of Protected Health Information

Only a parent or a legal guardian can request or consent to sharing of patient records. Please allow 3-5 business days for processing your request. This authorization is only applicable for services selected above and only upto the date of request. Any additional request for release of protected health information will require a separate authorization. Authorizing the disclosure of this healthcare information is voluntary. Once the information has been released according to the terms of this authorization, the information cannot be recalled.

Today's Date

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Authorization for the Release of Protected Health Information

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