records release form dental

Authorization for Release of Dental Records

Instructions for Use

• Complete all sections of this form in full, ensuring that the recipient’s contact information is accurate to avoid delays in processing.
• If you are signing on behalf of a patient, attach legal documentation (such as Power of Attorney or Guardianship papers) to this request.
• Submit the signed document directly to the office currently holding the records via secure email, fax, or in-person delivery.

Parties and Definitions

Patient Name: [] Date of Birth: [] Current Dental Provider: [] Recipient/New Provider: []

Operative Clauses

1. Authorization: I hereby authorize the Current Dental Provider identified above to release and transmit a complete copy of my dental records, including clinical notes, radiographs (X-rays), periodontal charts, and treatment plans, to the Recipient identified above.
2. Scope of Disclosure: I understand that this authorization includes the release of all records, including those related to [ ] All Records or [ ] Specific Dates: [__________].
3. Purpose: This request is made for the following purpose: [ ] Transfer of Care [ ] Second Opinion [ ] Insurance Review [ ] Personal Copy [ ] Other: [__________].
4. Revocation: I understand that I may 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 on this authorization.
5. 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 privacy regulations (HIPAA).
6. Fees: I acknowledge that the Current Dental Provider may charge a reasonable, cost-based fee for the copying and transmission of these records as permitted by applicable state law.
7. Expiration: This authorization shall remain in effect for [ ] 90 days [ ] 1 year [ ] Until the following date: [__________] from the date of signature.

Signature and Acknowledgment

By signing below, I confirm that I am the patient or the patient’s legal representative and that I have read and understood the terms of this authorization.

Signature: __________ Printed Name: [] Capacity (if signing for patient): [] Date: [__________]

LEGAL DISCLAIMER: This document is a general framework and does not constitute formal legal advice. Dental record privacy laws vary significantly by jurisdiction; please consult with qualified legal counsel or your state dental board to ensure compliance with local regulations.