patient authority to transfer records from another practice

Dear Patient,

In providing the most appropriate dental treatment for you in our practice, we believe it would be of great assistance to access information about your previous treatment from (Name of Previous Dentist):

To ensure compliance with the Federal and State Privacy Legislation we require your signed consent to authorize these records.

Please be aware that it is lawful for a practitioner to charge a fee to a patient requesting access to, and copies of, written records and other forms of diagnostic records such as radiographs, etc.

Any accounts which may be issued for these purposes will require your payment.

I give permission to
of Dentists of Ivanhoe Central

To seek copies of my dental records from (Name of Previous Practice)

Name: