Patient Information
PATIENT RESPONSIBILITYPERTINENCEREFERRALREGISTRATION FORMSREQUESTING SOCIAL SECURITY NUMBERCANCELLATION POLICYTARDINESSPAYMENT POLICYINDEPENDENT FINANCINGPREPAYMENT REQUIREMENT FOR DENTAL LAB WORKDENTAL INSURANCEINSURANCE PAYS SUBSCRIBEREMERGENCY APPOINTMENTINITIAL APPOINTMENT (NON-EMERGENCY)TREATMENT PLANAPPOINTMENT ORDERAPPOINTMENT CONFIRMATIONSCHEDULE CHANGESAPPOINTMENTS FOR FAMILIESREFUSAL OF TREATMENTRECORD TRANSFER REQUESTQUESTIONSDISCLAIMERHIPAA NOTICE OF PRIVACY PRACTICESRECORD TRANSFER REQUEST
A written request stating the name of the patient(s), the date, the name and address of the patient or the dental practice being transferred to, and signature of each adult patient will be required.There is no fee for secure e-mail transfer to another dental office. Secure e-mail to patient(s) is not feasible. If patients desire a hard copies to be sent, a fee for duplication may be charged.
The fee must be paid prior to the transfer of records. Please allow five (5) business days from receipt of the request and payment for completion.
If records transfer is requested, to a non-specialized dentist, the dentist-patient relationship with Dr Pepin and this office will be terminated. If you have voluntarily transferred and wish to return to this office after transferring/terminating, you are welcome to transfer back.
