orthodontic records release form

Authorization for Release of Protected Health Information

Instructions for Use

• Complete all sections of this form accurately to ensure the timely transfer of your clinical materials.
• Submit the signed form directly to the office currently holding your records via secure email, fax, or in-person delivery.
• Retain a copy of this signed authorization for your personal records to track the status of your request.

Parties and Definitions

Patient Name: [] Date of Birth: [] Current Provider/Practice: [] Receiving Provider/Practice: []

Operative Clauses

1. Authorization to Disclose: I hereby authorize the Current Provider named above to release the following orthodontic records to the Receiving Provider:

   • All clinical records, including treatment plans and progress notes.
   • Radiographic images (e.g., cephalometric, panoramic, or 3D scans).
   • Diagnostic models (digital or physical).
   • Clinical photographs.
   • Other: [__________]

2. Purpose of Disclosure: The purpose of this disclosure is to facilitate the continuity of orthodontic care, transfer of active treatment, or second opinion consultation.

3. Revocation: I understand that I have the right to revoke this authorization in writing at any time, except to the extent that the Current Provider has already taken action in reliance upon this authorization.

4. Re-disclosure: I understand 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. Fees: I acknowledge that a reasonable fee may be charged for the duplication and transfer of records, as permitted by applicable state law.

6. Expiration: This authorization shall remain valid for [__________] days from the date of signature unless revoked earlier in writing.

Signature and Acknowledgment

By signing below, I certify that I am the patient, or the parent/legal guardian authorized to act on behalf of the patient, and I voluntarily authorize the disclosure of the information described above.

Signature: __________

Printed Name: [__________]

Title/Relationship: [__________]

Date: [__________]

Legal Disclaimer: This document is a general framework intended for informational purposes and does not constitute legal advice. Please consult with qualified legal counsel or your local dental association to ensure compliance with jurisdiction-specific regulations, including HIPAA or provincial health privacy acts.