Port Charlotte Dentist     Medical Records Release     Charlotte County Dentistry

A Medical Records Release Authorization is required for Port Charlotte, FL Periodontist Carol W. Stevens, D.D.S., M.B.A., to retrieve your medical records from another doctor or medical facility. You can print this form, fill it out and mail it to our office, fax it to 941-743-2988, or bring it with you for your scheduled appointment. By submitting this form you are authorizing Periodontist Carol W. Stevens, D.D.S., M.B.A. to retrieve your medical records.

Download the PDF version here: Medical-Records-Release.pdf. This form requires a PDF Reader. You can download Acrobat Reader for free to view and print our forms.

We value your privacy and want you to be informed of how we may use and disclose your protected health information. For specifics about our policies, read our Privacy Practices.

 

Port Charlotte Dentist  MEDICAL RECORDS RELEASE AUTHORIZATION

Releasing Doctor: _______________________________________________

Releasing Facility: ______________________________________________

Address: ____________________________________  City: _________________ State: ____  Zip: _______

I hereby authorize and request you to release all available information and radiographs in your possession to:

Carol W. Stevens, D.D.S., M.B.A.
19180 Quesada Ave., Port Charlotte, FL 33948
941-743-7474

Port Charlotte Dentist  FROM THE MEDICAL RECORDS OF:

Full Name: ________________________________________________________

Address: ____________________________________  City: _________________ State: ____  Zip: _______

Date Signed: _______________________________ Authorizing Signature: ___________________________

Witness: ___________________________________    ___________________________________
                                                                                       (If Relative - State Relationship)

By submitting this form, I am in full agreement with the terms stated above. If you have any questions about this form please contact our office at 941-743-7474.