medical release form for dental office

Authorization for Release of Protected Health Information

Instructions for Use

• Complete all fields marked with brackets to ensure the facility can identify your records and the authorized recipient.
• Specify the exact date range or specific treatment records requested to ensure the release is narrowly tailored to your needs.
• Sign and date the document in the presence of a witness or office staff member if required by your specific state regulations.

Parties and Definitions

This Authorization is granted by [Patient Full Name] ("Patient"), whose date of birth is [Date of Birth], to the following dental practice:

Provider Name: [Dental Practice Name] Address: [Street Address, City, State, Zip Code] Phone: [Phone Number]

The Patient hereby authorizes the Provider to release the specified records to the following recipient:

Recipient Name: [Recipient/Entity Name] Address: [Street Address, City, State, Zip Code] Email/Fax: [Email Address or Fax Number]

Operative Clauses

1. Scope of Disclosure: The Provider is authorized to release the following information: [ ] All dental records, including clinical notes, radiographs, and treatment plans. [ ] Specific records only: [__________]. [ ] Records covering the period from [Start Date] to [End Date].

2. Purpose of Disclosure: The information is being released for the following purpose: [ ] Personal use/records. [ ] Transfer of care to a new provider. [ ] Insurance/Legal claim processing. [ ] Other: [__________].

3. Revocation: The Patient understands that this authorization is voluntary and may be revoked at any time by providing written notice to the Provider, except to the extent that the Provider has already taken action in reliance upon this authorization.

4. Re-disclosure: The Patient acknowledges that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

5. Expiration: This authorization shall remain in effect until [Expiration Date or Event], or if left blank, for a period of one (1) year from the date of signature.

6. Fees: The Patient acknowledges that the Provider may charge a reasonable, cost-based fee for the copying and transmission of these records as permitted by applicable law.

Signature and Acknowledgment

I have read and understand the terms of this authorization. I voluntarily authorize the disclosure of my dental records as described above.

Signature: __________ Printed Name: [Full Legal Name] Title (if signing as Personal Representative): [Representative Title] Date: [Date]

Legal Disclaimer: This document is a general framework intended for informational purposes only and does not constitute legal advice. Requirements for health information releases vary significantly by state and local jurisdiction (e.g., HIPAA compliance). Consult with qualified legal counsel to ensure this document meets all applicable regulatory requirements in your specific jurisdiction.