Records Release Form Please enable JavaScript in your browser to complete this form.I am transferring records for my child out of DPD Smiles to new provider. I understand that in order to do so, I need to provide the new provider's contact information and sign consenting to the transfer of records. According to IL State Law, your original records are property of this office and will remain in safe keeping for six-ten years. In compliance with state law the office reserves the right to be reimbursed for the cost associated with a transfer of records. A charge of $20 per family account is due before records can be transferred. The records will be transmitted via a HIPAA encrypted email service to protect your health information. Patient Name *FirstLastPatient Date of Birth *Parent Name *FirstLastConsent for digital communications *yesParental Signature for Release *Clear SignatureReason for Records Request: (Select All that Apply) *Changed Dental OfficeSpecialistInsurance RequestMovingOtherShould We Cancel All Future Appointments With Our Office? *YesNoNew Provider/Office Name *Email to Receive Records: *CommentSubmit
