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It captures essential patient identifiers, including full name, date of birth, and contact information, ensuring accurate record retrieval. The form provides multiple secure delivery options, such as mail services, in-person collection, or email transmission, with clear timeframes for processing. By requiring both a printed name and a formal signature, the clinic ensures compliance with authorization standards for sensitive health information management. This administrative tool facilitates professional communication between healthcare providers and their patients, supporting the seamless transition of dental care records while maintaining necessary documentation and security protocols for privacy and data protection within the clinical environment.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/bloomingdale-dental-patient-records-release-form/294926/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/bloomingdale-dental-patient-records-release-form/294926.png","ImageObject",300,407,{"name":92,"@type":93},"Patrick","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-18",true,{"@type":102,"interactionType":103,"userInteractionCount":34},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"How long does it take for the office to prepare dental records?","Question",{"text":112,"@type":113},"The office requires one week to prepare all records, though mailed records may take up to two weeks for delivery.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What methods can be selected for transferring records?",{"text":117,"@type":113},"Patients may choose between mail delivery, in-person pickup, or email, provided they circle the method and describe the relevant details.",{"name":119,"@type":110,"acceptedAnswer":120},"What information is required to submit this form?",{"text":121,"@type":113},"The form requires the patient's full name, date of birth, phone number, the name of the receiving clinic, and a formal signature for authorization.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},294926,1790252775,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":34,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81},549758146520,"https://ap-avatar.wpscdn.com/avatar/80002397d8c0411e94?_k=1775819394049821470","PATIENT RECORDS RELEASE FORM  \nDate:   \nPatient Name:   Date of Birth:   Phone number:   I authorize [insert name of dental clinic] to transfer my dental records to:  \nThrough the following methods (circle and describe all those that apply):  \n􀁸 Mail provide address (records will be sent within 2 weeks)  \n􀁸 In-person pick up   Please check if yes  \n􀁸 Email   \nPrint Name:   Signature:    \n*Please allow our office one week to get all records ready","cbCaicawOaTB3m4k","https://ap.wps.com/l/cbCaicawOaTB3m4k","pdf",485882,"English","# Patient Information\n## Authorization and Transfer Methods","[{\"question\":\"How long does it take for the office to prepare dental records?\",\"answer\":\"The office requires one week to prepare all records, though mailed records may take up to two weeks for delivery.\"},{\"question\":\"What methods can be selected for transferring records?\",\"answer\":\"Patients may choose between mail delivery, in-person pickup, or email, provided they circle the method and describe the relevant details.\"},{\"question\":\"What information is required to submit this form?\",\"answer\":\"The form requires the patient's full name, date of birth, phone number, the name of the receiving clinic, and a formal signature for authorization.\"}]","Bloomingdale Dental - Patient Records Release Form | PDF",1789711253]