All requests must include the following:
- Patient’s full name
- Date of birth
- Verification of Indentity (Driver’s License, ID Card, Passport, etc.)
- Name, address, and telephone number where the records are to be sent
- Purpose of the request
- Specific items or dates of service needed
- Any restrictions on the request
- Date of the request
- Signature of the patient or, if the patient is a child, the parent or guardian
- Date this authorization expires (authorizations must be less than one year old)
- If signed by a personal representative, a description of his/her authority to act for the individual and a copy of the document giving that authority.
Email request to:
Fax request to:
- (352) 273-5344
Mail request to:
- University of Florida – College of Dentistry
Dental Records
P.O. Box 100425
Gainesville, FL 32610-0425