dental office release of records form

Authorization for Disclosure of Dental Health Information

Instructions for Use

• Complete all fields clearly using black or blue ink, ensuring the patient's name and date of birth match office records exactly.
• Specify the exact timeframe and type of records requested to ensure the dental office can process your request efficiently.
• Sign and date the document; if you are signing on behalf of a patient, attach legal documentation of your authority (e.g., Power of Attorney or Guardianship).

Parties & Definitions

Patient Name: []
Date of Birth: []
Patient Address: []
Requesting Entity/Person: []
Current Dental Provider: [__________]

Operative Clauses

1. Authorization: I hereby authorize the Current Dental Provider listed above to disclose my protected dental health information to the Requesting Entity/Person identified above.

2. Scope of Records: I authorize the release of the following information (check all that apply):

   • All dental records (including clinical notes, treatment plans, and billing history)
   • Radiographs (X-rays, Panorex, CBCT, or intraoral photos)
   • Periodontal charting
   • Other: [__________]

3. Purpose of Disclosure: The purpose of this disclosure is:

   • Transfer of care to a new provider
   • Insurance claim processing
   • Personal records
   • Legal/Litigation purposes
   • Other: [__________]

4. Expiration: This authorization shall remain in effect for [__________] days from the date of signature unless revoked by me in writing.

5. Right to Revoke: I understand that I have the right to revoke this authorization at any time by providing written notice to the Current Dental Provider, except to the extent that action has already been taken in reliance upon this authorization.

6. Re-disclosure: I understand that once my dental health information is disclosed to the Requesting Entity/Person, it may no longer be protected by federal privacy regulations (such as HIPAA) and may potentially be re-disclosed by the recipient.

7. Fees: I understand that the Current Dental Provider may charge a reasonable, cost-based fee for the preparation and transmission of these records as permitted by applicable state and federal law.

Signature & Acknowledgment

I have read and understood the terms of this authorization and voluntarily grant my consent for the disclosure of my dental records.

Signature: []
Printed Name: []
Relationship to Patient (if not self): []
Date: []

Legal Disclaimer: This document is a general framework intended for informational purposes only and does not constitute legal advice. Requirements for health information privacy vary by jurisdiction. You should consult with qualified legal counsel to ensure this document complies with all applicable state and federal laws (including HIPAA) in your specific location.