records release form dental office

Authorization for Release of Dental Records

Instructions for Use

• Complete all sections of this form clearly and ensure all relevant fields are filled to prevent delays in processing your request.
• If you are signing on behalf of a patient, attach legal documentation verifying your authority (e.g., Power of Attorney or Guardianship papers).
• Submit the signed original to the dental office’s administrative department via secure email, fax, or in-person delivery.

Parties and Definitions

Patient Name: []
Date of Birth: []
Patient Address: []
Releasing Office: [] ("Disclosing Party")
Recipient Name/Office: [] ("Recipient")
Recipient Address: []

Operative Terms

1. Authorization: I hereby authorize the Disclosing Party to release my dental records, including clinical notes, radiographs, treatment plans, periodontal charts, and billing history, to the Recipient named above.
2. Scope of Disclosure: I authorize the release of:
   • All records for all dates of service.
   • Records for the period beginning [] and ending [].
   • Specific records (please describe): [__________].
3. Purpose: This information is being requested for the following purpose:
   • Continued dental care / Transfer of records.
   • Insurance claim processing.
   • Legal or personal use.
   • Other: [__________].
4. Revocation: I understand that I may revoke this authorization at any time by providing written notice to the Disclosing Party, 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 or state privacy laws.
6. Conditioning: I understand that the Disclosing Party will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.
7. Expiration: This authorization shall remain in effect for [] days from the date of signature unless an earlier date is specified here: [].

Signature and Acknowledgment

I have read and understand the terms of this authorization and voluntarily grant my consent for the release of the specified records.

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

Legal Disclaimer: This document is a general framework provided for informational purposes only. It does not constitute legal advice. Please consult with qualified legal counsel to ensure compliance with HIPAA, state-specific privacy statutes, and dental board regulations in your jurisdiction.