Please complete this form to have your or your child's dental records sent to a dental provider of your choice. Please call Tri-County Health Network at (970) 708-7096 with any questions.

Patient information

Patient full name:*

Patient date of birth:*

Patient school (if applicable):

Patient street address:*

Zip code:*

I authorize any member of the medical staff of Tri-County Health Network and/or any of its employees or representatives to use and/or disclose my or my child’s protected health information (PHI) as provided below. I understand that I may revoke this Authorization, except to the extent that the entity has already taken action in reliance on this Authorization. The provision of treatment will not be conditioned on the completion of this Authorization. I understand that once the PHI listed below is used or disclosed as set forth in this Authorization, such information is subject to re-disclosure and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Information to be disclosed to:

Clinic name:*

Dentist name:

Clinic phone number:*

Clinic street address:

Clinic zip code:

Information to be disclosed:

X-raysYesNo

Complete medical recordsYesNo

I understand that state law prohibits the use and/or disclosure of the PHI listed above unless specifically authorized by me. I understand that such information will not be used or disclosed unless I indicate by signing below.

Electronic Signature Agreement: The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Patient signature (or parent/guardian signature if patient is a minor)*

(Use your mouse or trackpad to sign.)

Printed Name of Signer*

Relationship to patient*

Phone *

Today's Date*

Email*