Brilliant Dental LLC 630-969-6688 Fax 888-501-3533
Patient’s Name (print):________________________________________________________________
Date of Birth: ______________________________________ (for identification purposes)
Describe the records you wish to access and the approximate dates of the records:______________________________________________________________________________________________________________________________________________________________________What would you like for us to do for you?
Fees Our practice charges a reasonable, cost-based fee to for copies of patient information, and for postage to mail records if requested.
Questions? Please contact our privacy official listed at the top of this page if you have any questions about your request to inspect or copy records.
If the request is by a patient:Patient
If the request is by a patient’s personal representative:
Print the Name of the Personal Representative: ____________________________________________
Relationship to the patient:_______________________________________
I certify that I have the legal authority under federal and state laws to make this request on behalf of the patient identified above.Signature of Personal Representative:_______________________________________ Date:_______________________
For Dental Office Use Only
Request for access denied (attach written denial).
Request for access approved.