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Records Release Authorization to Shirer Family Dentistry, LLC

Records Release Authorization to Shirer Family Dentistry, LLC 2025

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The document is a Records Release Authorization form allowing a patient to request the transfer of their dental records, including treatment notes and radiographs, from their current dentist to Shirer Family Dentistry, LLC. It includes fields for the patient's personal information, the current dentist's details, and a signature for authorization.

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Click ‘Get Form’ to open the Records Release Authorization in our platform's editor.
Begin by entering your full name in the designated field for 'Patient'. This ensures that your records are accurately identified.
Next, fill in your date of birth. This information is crucial for verifying your identity and accessing the correct records.
Provide your current address and telephone number. This allows Shirer Family Dentistry, LLC to contact you if needed.
In the section labeled 'Records released from the office of', enter the name of your previous dentist along with their address and telephone number. This identifies where your records are coming from.
Finally, sign and date the form at the bottom. Your signature authorizes the release of your records to Shirer Family Dentistry, LLC.

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