Willamette Dental provides records duplication
for the following:
- Dental Charts (90029) ($10)
- X-rays (90028) ($10)
- Orthodontia Model ($30)
To obtain duplication of your charts
and x-rays, please fill out the following form and submit it to
Willamette Dental with payment:
Authorization
to Duplicate, Use, or Disclose Protected Health Information
Please Note:
- Only patients over 18 years of age are allowed to request their own charts & x-rays.
Patients under 18 years of age must have a parent request charts &
x-rays directly from Willamette Dental.
- Willamette Dental requires proof of guardianship for a foster child. A copy of proof
must be mailed to the address listed below or hand
delivered to the Willamette Dental office where treatment is
provided.
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Payment
Payment for records duplication is due at
the time of request. Duplication of records will be processed within 14
days of receipt of payment.
Please send your payment, in the form of a check, with your completed form directly to Willamette Dental.
Willamette Dental Records*
7729 SW Nimbus
Beaverton, OR 97008
*Please make checks payable to Willamette Dental
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