Phone: 770.925.3300 | TeboDental.com

Patient Request for Information

To our patients and their personal representatives:

If you want to inspect or copy dental or billing records, please fill out this form and give it to any staff member or mail it to: Tebo Dental Group, Attention: Records, P.O. Box 1953, Lilburn, Georgia 30048-1953.

Except as noted below, there is a charge for copying paper records, for duplicating x-rays, for postage (if applicable) and for preparing any written summary or written explanation that you may request. We will notify you of the charge for preparing a summary or explanation and you will have an opportunity to cancel the request for the summary or explanation if you do not agree with the charge. Please let us know if you want an estimate of the charges for copying paper records or duplicating x-rays. All charges must be paid before records are released, unless other arrangements have been made with the office. There is no charge for records for Medicaid patients or PeachCare patients.

*Patient name:

*Date of birth:

*Please tell us the information you want (please check all that apply):

Dental records (excluding x-rays, unless “X-ray duplicates” also checked below)

X-ray duplicates

Billing records

School Form 3300

School excuse

Summary (what you want summarized?):

Explanation (what do you want explained?):

Special instructions:

*Please tell us what to do with the patient’s information (please check only one):

Hold and call me to arrange an inspection of the records

Hold for pick up by me

Hold for pick up by:

Fax to me at (fax no.):

Mail to me at (address):

Email to me at (address):

Send to this person or office:

By fax to (fax no.):

By mail to (address):

By email to (address):

*Signature of patient or Parent/Guardian

Date signed:

*Signed by:

Parent/Guardian

Patient

*If signed by the patient’s Parent/Guardian, basis of Parent/Guardian’s authority:

*Parent/Guardian’s name:

*Phone:

*Parent/Guardian’s address: