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 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?

• I wish to see the requested records.
• I wish to get a copy of the requested records.
• I wish to see and get a copy of the requested records.If the requested records are in an electronic designated record set,
• I wish an electronic copy of the requested records If you would like the information emailed, enter the email address here (PLEASE PRINT VERY CLEARLY!): __________________________@______________________________We do not recommend sending patient information in an unencrypted email because third parties may be able to access the email.
• I want you to prepare summary of the requested records and I agree in advance to paya fee in the amount of $_________.
• I want you to prepare an explanation of the records that I saw or got a copy of, andI agree in advance to pay a fee in the amount of $_________.
• Third party recipient  I want you to send the copy of the requested records to:  Name:___________________________________________________________________________ Address:_ _________________________________________________________________________

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 

Signature:______________________________________________ Date:_______________________

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.