records release dental

Authorization for Release of Dental Records

Instructions for Use

• Complete all sections of this form accurately; incomplete forms may delay the processing of your request.
• Submit the signed original to the dental office currently holding your records via secure email, fax, or in-person delivery.
• If you are requesting records for a minor or a dependent, ensure the legal guardian or authorized representative signs in the appropriate section.

Parties and Definitions

This Authorization is made by [Patient Full Name], residing at [Patient Address], date of birth [Date of Birth] ("Patient"), and directed to [Current Dental Practice Name], located at [Practice Address] ("Disclosing Party").

The Patient hereby authorizes the Disclosing Party to release the following Protected Health Information (PHI) to: Name of Recipient: [Recipient Name/Practice] Address/Email: [Recipient Contact Information]

Operative Clauses

1. Scope of Disclosure: The Disclosing Party is authorized to release the following specific records:

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

2. Purpose of Disclosure: The purpose of this release is:

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

3. Expiration: This authorization shall remain in effect for [Number] days from the date of signature, unless revoked earlier in writing by the Patient.

4. Right to Revoke: The Patient understands that they have the right to revoke this authorization at any time by providing written notice to the Disclosing Party, except to the extent that the Disclosing Party has already taken action in reliance upon this authorization.

5. Re-disclosure: The Patient acknowledges that once the PHI is disclosed to the Recipient, the information may no longer be protected by federal privacy laws (e.g., HIPAA) and may be subject to re-disclosure by the Recipient.

6. Conditioning: The Disclosing Party may not condition treatment, payment, enrollment, or eligibility for benefits on the Patient’s signing of this authorization.

Signature and Acknowledgment

By signing below, I acknowledge that I have read and understand this authorization, and I voluntarily consent to the disclosure of my dental records as described above.

Signature: __________ Printed Name: [] Title (if signing as representative): [] Date: [__________]

Legal Disclaimer: This document is a general framework intended for informational purposes only. It does not constitute legal advice. Please consult with qualified legal counsel or your local dental association to ensure compliance with jurisdiction-specific privacy laws and medical record retention regulations.